Avamere Rehabilitation of Coos Bay

On 8/21/25 at 2:34 PM Staff 2 (DNS) stated Resident 3 was her/his own responsible party and staff did not have to notify family of hospitalizations.-á-á

Resident 41 admitted to the facility on 8/16/24 with diagnoses including heart failure and pain.-áA 6/14/25 physician order instructed staff to complete weekly skin checks on the resident's shower days and document on the Weekly Skin Audit.-á-áA 7/14/25 physician order instructed staff to administer apixaban 5 mg (anticoagulant) two times a day for blood clots.-áResident 41GÇÖs Annual MDS completed on 8/7/25 revealed a BIMS score of 9, which indicated the resident had moderate cognitive impairment.-áThe 8/15/25 Alert Note indicated the nurse was notified Resident 41 had a long, dark bruise on the underside of her/his right breast. Resident 41 was unable to explain how the bruising occurred and did not complain of pain.-áNo documentation was found to indicate staff notified the State Agency.On 8/19/25 at 10:53 AM, Resident 41 was unable to recall if she/he had any bruises.On 8/20/25 at 4:04 PM, Staff 17 (LPN) confirmed on 8/14/25 he was notified Resident 41 had a large bruise on her/his right breast. The resident did not recall how the bruise occurred. Staff 17 noted the resident was on anticoagulant medication and bruised easily. Staff 17 initiated a risk management report but did not report the incident to the State agency.On 8/21/25 at 4:42 PM, Staff 2 (DNS) was asked to provide copies of all internal and facility reported incidents (FRIs) that involved alleged abuse. Staff 2 confirmed on 8/14/25 staff identified a bruise on Resident 41, the resident was unable to state how the bruise was acquired, and the incident was not reported to the State agency.

-á3. Resident 56 was admitted to the facility in 8/2023 with diagnoses including acute respiratory failure with hypercapnia (excess carbon dioxide in the blood) and chronic systolic heart failure (long-term condition where the heart has difficulty pumping blood).-á -áProgress Notes indicated Resident 56 was admitted to the hospital on 5/26/25.-áA review of Ombudsman Notice of Residents Discharge forms for 6/2025 and 7/2025 did not include Resident 56's name.-áOn 8/22/25 at 10:47 AM, Staff 12 (Social Services) stated she sent a monthly fax to the Long-Term Care Ombudsman's (LTCO) office listing all resident discharges. No additional information was provided.-áOn 8/22/25 at 11:25 AM, an attempt to contact the LTCO office was not successful.-áOn 8/22/25 at 11:49 AM, Staff 2 (DNS) stated the LTCO office would be expected to be notified monthly if a resident went to the hospital and returned. If a resident died, the LTCO office would be expected to be notified as soon as the facility became aware of the death.-á

Resident 41 admitted to the facility on 8/2024 with diagnoses including heart failure and pain.-áA 6/14/25 physician order instructed staff to complete weekly skin checks on the resident's shower days and document any skin irregularities on the Weekly Skin Audit.-á-áA 7/14/25 physician order instructed staff to administer apixaban 5 mg (anticoagulant) two times a day for blood clots.-áResident 41GÇÖs 8/7/25 Annual MDS revealed a BIMS score of 9, which indicated the resident had moderate cognitive impairment.-áThe 8/15/25 Alert Note indicated the nurse was notified Resident 41 had a long, dark bruise on the underside of her/his right breast. Resident 41 was unable to explain how the bruising occurred and did not complain of pain.-áResident 41GÇÖs 8/21/25 care plan indicated the resident was on anticoagulant therapy for blood clots. The goal was for the resident to remain free from adverse reactions related to anticoagulant use. Staff were directed to report abnormalities to the nurse, document, and report bruising.On 8/20/25 at 3:56 PM, Staff 33 (CNA) stated on 8/14/25 she identified a large bruise on Resident 41GÇÖs right breast and reported the findings to the charge nurse.On 8/20/25 at 4:04 PM, Staff 17 (LPN) confirmed he was notified Resident 41 had a bruise on her/his right breast, the resident did not recall how she/he got the bruise, she/he was on anticoagulant medication, and bruised very easily. Staff 17 initiated a risk management and notified management but did not update the care plan.On 8/21/25 at 4:42 PM, Staff 2 (DNS) confirmed Resident 41 had a physician order for anticoagulant medication and it was not on the care plan.-á-á-á

3. Resident 21 was admitted to the facility in 6/2025 with diagnoses including diabetes and visual loss. -áAn 8/2025 BIMS assessment indicated Resident 21 was cognitively intact.-á-áAn 8/13/25 Progress Note indicated a provider order was received for Bactrim DS 800-160 mg (an antibiotic medication) to be taken twice a day for seven days.-á-áAn 8/13/25 Progress Note indicated a provider order to decrease Resident 21GÇÖs Lantus insulin (diabetic medication) from ten units twice a day to five units twice a day.-á-á-áA provider order for Lantus insulin five units twice a day was entered into Resident 21GÇÖs chart on 8/13/25.-áAn 8/14/25 Progress Note indicated Resident 21 received ten units of Lantus insulin during the morning 7:00 GÇô 10:00 AM administration window.-á-áA provider order for Bactrim DS 800-160 mg twice a day for seven days was entered into Resident 21GÇÖs chart on 8/14/25.-á-áA review of Resident 21GÇÖs 8/2025 Diabetic Administration Record revealed the following:-á-áOn 8/14/25 in the 7:00 - 10:00AM administration window ten units of Lantus insulin were administered, and then the order was discontinued.-áOn 8/20/25 at 12:30 PM, Resident 21 stated she/he was aware of mistakes made with her/his insulin and antibiotic medications earlier in the month.-á-áOn 8/25/2025 at 10:23 AM, Staff 2 (DNS) acknowledged the medication errors and stated her expectation was for provider orders to be double checked for accuracy by two nurses on different shifts for any new medication, any changes to medications, and prior to any medications being discontinued.-á-á4. Resident 59 was admitted to the facility in 12/2024 with diagnoses including left sided Hemiplegia (paralysis of the left side) and intracerebral hemorrhage (a type of stroke).-á-áReview of a 2/12/25 Facility Reported Incident (FRI) indicated Resident 59 missed multiple administrations of Isosource Enteral Feed 1.5 (liquid food given though a tube) 300 ml via G-Tube (a flexible tube inserted into the stomach through the abdomen) from 2/1/25 through 2/5/25.-á-áA provider order for Isosource 1.5 300 ml via G-Tube at HS was started on 1/31/25 and was incorrectly discontinued on 2/1/25.-áA 2/1/25 Progress Note indicated Resident 59 was eating food by mouth and was no longer receiving the Isosource 1.5 300 ml via G-Tube.-á-áAnother provider order for Isosource 1.5 300 ml via G-Tube at HS was started on 2/6/25.-á-áA review of Resident 59GÇÖs 2/2025 MAR indicated she/he did not receive the HS administration of Isosource 1.5 300 ml via G-Tube from 2/1/25 through 2/5/25. -áAlert notes from 2/7/25 through 2/10/25 indicate Resident 59 had no adverse effects from the missed administrations of Isosource 1.5 300 ml via G-Tube at HS.-áOn 8/25/2025 at 10:23 AM, Staff 2 (DNS) acknowledged the medication error and stated her expectation was for provider orders to be double checked for accuracy by two nurses on different shifts for any new medication, any changes to medications, and prior to any medications being discontinued. 2. Resident 5 admitted to the facility in 4/25 with diagnoses including end stage kidney disease and Type I diabetes. -áThe facilityGÇÖs 2024 Standing Physician Orders for diabetic management instructed staff to inject 1 gram glucagon when diabetic residents became unresponsive, or capillary blood glucose (CBG) was below 70 mg/dL.-áThe 4/30/25 Admission MDS revealed Resident 5 had a BIMS of 13, which indicated the resident was cognitively intact.Resident 5GÇÖs 6/2025 Diabetic Administration Record (DAR) did not include standing orders for glucagon injections. No documentation was found to indicate staff administered glucagon on 6/5/25 or 6/29/25 when the residentGÇÖs CBGs were below 70 mg/dL.Progress notes from 6/5/25, 6/29/25, 7/6/25, and 7/24/25 revealed severe hypoglycemia (blood glucose ranging 31-51mg/dL) and hospital transfers. On 7/6/25 and 7/24/25, staff were unable to locate glucagon injections in the facility, requiring emergency transport to the hospital.A 7/31/25 Physician order instructed staff to maintain glucagon injections in the emergency kit. Staff were to inject 1 mg glucagon every 12 hours PRN for low CBG related to hypoglycemia.-áOn 8/21/25 at 9:06 AM, Staff 18 (LPN) confirmed the emergency kit did not include any glucagon injections. Staff 18 stated all diabetic residents should have standing orders for glucagon injections and gel, available on the medication cart.On 8/21/25 at 9:20 AM, Staff 17 (LPN) stated within the past few months, the facility ran out of glucagon injections on several occasions. During this time, Resident 5 frequently experienced low CBG levels, and required hospitalization due to hypoglycemia. Staff 17 further stated nurses were responsible for ordering additional doses however, there were sometimes delays in the pharmacy delivering the injections.On 8/21/25 at 4:36 PM, Resident 5 reported having multiple hospitalizations in recent months due to hypoglycemia. Resident 5 stated she/he was afraid to go to sleep at night due to frequent drops in her/his CBGs.On 8/22/25 at 12:40 PM, Staff 2 (DNS) and Staff 11 (Regional Director of Quality Assurance) confirmed the facility failed to follow standing orders and maintain sufficient glucagon supplies, contributing to multiple hospitalizations for Resident 5.-áb. The 6/9/25 Hospital After Visit Summary revealed Resident 5 was seen from 6/5/25 through 6/9/25 for hypoglycemia. A follow-up appointment was scheduled for 6/12/25. The physician referral orders indicated Resident 5 was to be enrolled in a continuous glucose monitoring (CGM) program.-áA 7/6/25 nephrology referral revealed due to Resident 5GÇÖs multiple hospitalizations related to either hyperglycemia or hypoglycemia, the resident was determined to have brittle diabetes (highly unpredictable blood glucose levels). The nephrologist recommended enrollment in a CGM program.The 7/31/25 Hospital After Visit Summary revealed a physician prescribed CGM. Medication changes included Dexcom G7 (blood-glucose) Receiver and Dexcom G7 (blood-glucose) Sensor.No documentation was found to indicate the facility followed through with the physiciansGÇÖ orders.-áOn 8/22/25 at 9:45 AM, Staff 32 (RCM) stated when residents are admitted or re-admitted with new orders, the facility used its triple check system to ensure orders were accurately entered. Staff 32 was unable to provide documentation Resident 5GÇÖs physician orders from 6/12/25, 7/6/25, and 7/31/25 were followed up on.On 8/22/25 at 12:40 PM, Staff 2 and Staff 11 confirmed the facility failed to follow up with physician orders related to Resident 5GÇÖs diabetic management.-áResident 3's 6/2025 MAR revealed her/his fluid restriction was discontinued on 6/19/25.Resident 3's 7/2025 and 8/2025 TAR revealed her/his weights were monitored daily unless refused. The daily weights were discontinued on 8/11/25. The TARs did not indicate Resident 3's legs were monitored for edema.-áResident 3's Progress Notes dated 6/19/25 through 8/19/25 revealed one note on 6/22/25 which addressed her/his lower extremity edema.-á

Resident 52 was admitted to the facility in 7/2025 with diagnoses including fracture of left leg, anxiety, and difficulty in walking.-áThe care plan dated 7/12/25 identified Resident 52 as high risk for falls. Staff were instructed to keep her/his call light within reach at all times and ""DO NOT"" leave the resident unsupervised in the bathroom or on the bedside commode.-áA 7/16/25 Admission MDS BIMS assessment indicated a score of 13 (cognitively intact).-áOn 8/20/25 at 8:05 AM, the call light time log showed Resident 52 activated her/his call light at 7:45 AM.-á Staff 17 (LPN Charge Nurse) entered the room the room at 8:06 AM-21 minutes later.-áOn 8/20/25 at 8:30 AM Staff 17 stated he entered Resident 52's room because the call light had been on for a while.-á At-á8:36 AM Resident 52 stated she had been waiting on the bedside commode, and her/his buttocks were getting sore. Resident 52 reported self-transferring back to bed. Resident 52 was observed in bed with a gait belt around her/his upper waist. Resident 52 stated Staff 17 entered the room after she/he had already self-transferred.-áOn 8/21/25 at 10:58 AM, Staff 14 (CNA) stated she assisted Resident 52 onto the bedside commode on 8/20/25. She then informed other staff by radio she needed to complete a shower for another resident. After finishing the shower, she saw Resident 52's call light was on and again informed staff by radio.-á Staff 14 stated she did not know Resident 52 was not to be left alone on the bedside commode.-áOn 8/22/25 at 11:57 AM, Staff 2 (DNS) confirmed Resident 52 was care planned to be supervised while on the bedside commode.

1. Resident 6 was admitted in 7/2025 with diagnoses including kidney failure and muscle weakness.-áThe Admission MDS dated 7/15/25 identified the resident as frequently incontinent of urine and she/he required assistance with toileting. Resident 6 was cognitively intact and did not have any behaviors of rejection of care.-áThe 7/15/25 Urinary Incontinence CAA identified frequent incontinence and dependance on staff for safe completion of toileting hygiene and needs.-á-áResident 6's care plan dated 7/23/25 directed staff to encourage the use of the call light for assistance, offer frequent toileting opportunities, provide frequent check and change throughout each shift, and perform peri care after each incontinent episode.A Documentation Survey Report for bladder from 8/1/25 through 8/18/25 revealed the following for Resident 6:-Day shift: incontinent 11 times, both continent and incontinent five times, continent two times, no documentation one time. No documentation of refusals.-Evening shift: incontinent nine times, both continent and incontinent four times, continent seven times, and no documentation of refusals.-áOn 8/21/25 at 6:08 AM and 8/22/25 at 7:05 AM, Resident 6 stated it was easier to wear a brief than to wait for staff for assistance. Resident 6 confirmed having soaked through her/his wheelchair, leaving urine on the floor on 8/17/25. Resident 6 reported difficulty receiving timely assistance from staff to transfer into bed for incontinence care.-áOn 8/22/25 at 6:45 AM Staff 8 (CNA) stated she was "" so pissed"" staff assisted Resident 6 up for lunch, on 8/17/25 and she later assisted with dinner. Between lunch and dinner, Resident 6 remained in her/his wheelchair without receiving incontinence care. Resident 6 urinated all over herself/himself. Staff 8 stated Resident 6 urinated on herself/himself during dinner, leaving a large puddle on the floor.-á-áOn 8/22/25 at 9:03 AM Staff 4 (CNA) stated she assisted Resident 6 up for lunch and provided incontinence care on 8/17/25. Staff 4 stated she did not provide any incontinence care after lunch.-áOn 8/22/25 at 10:58 AM Staff 5 (CNA) stated he worked the evening shift on 8/17/25 and was assigned to the same hall as Resident 6. He could not recall if he was specifically assigned to Resident 6 but remembered assisting with incontinence care. Staff 5 recalled the evening being very busy and stated Resident 6's urine ""maybe"" was on the floor and he helped clean the urine up.-áOn 8/22/25 at 11:44 AM Staff 2 (DNS) stated staff were expected to check on residents every two hours and offer to lay them down in bed. If a resident refused assistance, staff are to notify the nurse.-á2. Resident 15 was admitted in 5/2025 with diagnoses including benign prostatic hyperplasia (non-cancerous enlargement of the prostate) with lower urinary symptoms.-áThe Admission MDS dated 5/14/25 identified Resident 15 as cognitively intact and frequently incontinent of both bladder and bowel. Resident 15 also required the assistance of staff for incontinence care.-áThe care plan dated 5/15/24 directed staff to encourage the use of the call light for assistance and to offer frequent toileting opportunities.-áA Resident Family Grievance Communication Form dated 8/11/25 documented on 8/10/25, Resident 15 requested a brief change at 1:10 PM.-á At 2:10 PM, Staff 5 entered the room and was informed assistance was still needed. Staff 5 stated he was told Resident 15 had already received incontinence care.-áA Documentation Survey Report for bladder from 8/1/25 through 8/12/25 revealed the following for Resident 15:-Day shift: incontinence two times, both continent and incontinent 12 times, and continent four times with no documentation of refusals.-Evening shift: incontinent six times, both continent and incontinent four times, and continent two times with no documentation of refusals.-áOn 8/21/25 at 10:49 AM, Staff 5 stated on 8/10/25, Resident 15 reported being soaked through her/his brief and did not receive staff assistance, there was urine on the floor under her/his wheelchair, and Resident 15 requested to file a grievance.-áOn 8/22/25 at 10:27 AM, Resident 15 confirmed timely incontinence care was not provided on 8/10/25.-áOn 8/22/25 at 12:01 PM, Staff 2 (DNS) stated staff were expected to provide timely incontinence care, check on residents every two hours, and offer to lay them down in bed. If a resident refused assistance, staff were to notify the nurse.

Resident 6 was admitted in 7/2025 with diagnoses including sleep apnea and edema (swelling caused by fluid retention).Per the facility's Oxygen Administration policy and procedure, documentation must include:-Date and time of oxygen setup or adjustment-Oxygen flow rate, route, and rationale-Frequency and duration of treatment-Reason for PRN administration-Assessment data before, during, and after the procedure-ResidentGÇÖs tolerance of the procedure-áThe Admission MDS dated 7/15/25 identified Resident 6 was cognitively intact and exhibited no behaviors. Resident 6 was not on oxygen therapy.A physician order dated 8/7/25 instructed staff to administer oxygen at two liters per minute via nasal cannula PRN for shortness of breath. No start date was listed. There was no documentation of oxygen tubing changes or cleaning of the oxygen concentrator filter.An 8/9/25 PhysicianGÇÖs Progress Note stated Resident 6 frequently complained of dyspnea (difficulty breathing), although oxygen saturation was good. Oxygen was provided to relieve the sensation.The O2 Saturation Summary Report from 8/7/25 through 8/21/25 revealed oxygen use via nasal cannula on the following dates and times:-8/8/25 at 6:52 AM-8/11/25 at 8:12 AM and 4:07 PM-8/12/25 at 6:34 AM and 2:34 PM-8/13/25 at 6:36 AM-8/14/25 at 6:52 AM-8/20/25 at 10:09 AM, 3:06 PM, and 10:33 PM-8/21/25 at 7:13 AM, 8:44 AM, 2:58 PM, and 6:36 PMReview of Resident 6's 8/2025 MAR and TAR from 8/1/25 through 8/20/25 contained no documentation of Resident 6's PRN oxygen therapy.-áThe care plan dated 8/12/25 identified a risk for ineffective breathing pattern due to edema and positioning. Interventions included:-Administer oxygen as prescribed or per standing order-Encourage coughing, deep breathing, and forced expiratory techniques as ordered-Evaluate pulse oximetry (measurement of oxygen saturation)On 8/21/25 at 6:08 AM, Resident 6 stated she/he used oxygen while sleeping and wore the nasal cannula most of the time. Resident 6 was observed wearing a nasal cannula with oxygen in use.On 8/21/25 at 7:37 AM, Witness 5 stated Resident 6 used oxygen part of the time.-áOn 8/21/25 at 9:20 AM, Staff 7 (CNA) stated Resident 6 always used oxygen during her shifts.-áOn 8/21/25 at 9:37 AM, Staff 9 (Physical Therapist Assistant) stated Resident 6 relied on oxygen.-áOn 8/22/25 Staff 2 (DNS) confirmed there was no documentation on the MAR or TAR of Resident 6GÇÖs use of oxygen and she would also expect an oxygen tubing and filter cleaning schedule.

5. Resident 61 was admitted to the facility in 8/2025 with diagnoses including diabetes and traumatic subdural hemorrhage (bleeding in the brain caused by trauma).-áOn 8/18/2025 at 4:16 PM, Resident 61 stated she/he had to wait GÇ£quite a long timeGÇ¥ on 8/17/25 and 8/18/25 to get help from staff.-áA review of the Call Light Audits for 8/17/25 and 8/18/25 revealed the following call light durations:8/18/25 at 12:22 AM - 1 hour 7 minutes,8/18/25 at 6:11 AM - 39 minutes,8/18/25 at 10:35 AM - 31 minutes,8/18/25 at 1:23 PM - 28 minutes, and8/18/25 at 10:51 PM - 25 minutes.-áOn 8/25/2025 at 10:18 AM, Staff 2 (DNS) acknowledged the call light durations and stated her expectation was all staff were responsible for responding to call lights in five to fifteen minutes, no matter what shift, or what was going on in the building.-á2. Resident 7 was admitted to the facility in 6/2024 with diagnoses including fracture of left femur.The care plan dated 3/12/25 identified Resident 7 required assistance with ADLs including repositioning and toilet use. -áAn Annual MDS BIMS assessment dated 6/10/25 indicated a score of 15 (cognitively intact).A Resident Family Grievance Communication Form dated 8/10/25 revealed Resident 7 activated her/his call light to request assistance with a bedpan. The resident waited one hour before staff entered the room. A few minutes before shift change, Resident 7 was assisted onto the bedpan. After completing use, the resident activated the call light again. No staff responded until shift change was completed. The facility response indicated the call light was activated at 1:31 PM and remained on for 35 minutes.-áOn 8/18/25 at 1:35 PM, Resident 7 stated on 8/10/25 she/he activated her/his call light and was on the bed pan for 20 to 30 minutes. Resident 7 had to wait until the evening shift came on before being assisted off the bed pan. Resident 7 stated she/he completed a grievance.On 8/21/25 at 10:49 AM, Staff 5 (CNA) stated Resident 7 was upset on 8/10/25 and reported she/he waited for assistance for an hour without a response from staff. Staff 5 assisted the resident to complete a grievance form.On 8/22/25 at 12:01 PM, Staff 2 (DNS) stated staff were expected to respond to call lights within five to 10 minutes, and no more than 15 minutes.-á3. Resident 24 was admitted to the facility in 7/2024 with diagnoses including respiratory failure and kidney diseaseThe care plan dated 10/4/24 identified Resident 24 as incontinent of bowel and bladder. The resident was encouraged to use the call light for assistance.A Quarterly MDS BIMS assessment dated 6/13/25 indicated a score of 14 (cognitively intact).A Resident Family Grievance Communication Form dated 8/7/25 revealed Resident 24's call light remained on for one hour and 20 minutes without response.-áThe Past Calls report for call light log 8/12/25 through 8/14/25 and 8/16/25 showed the following:-á-8/13/25 at 12:45 PM, the call light was on for over 25 minutes without response.-8/16/25 at 9:34 AM the call light was on for over 26 minutes without response.On 8/18/25 at 12:14 PM, Resident 24 stated call light response times were too long. The resident reported one instance took 45 minutes for staff to respond. Resident 24 stated long call light wait times frequently occurred in the afternoons and resulted in multiple episodes of incontinence.On 8/22/25 at 12:01 PM Staff 2 (DNS) stated staff were expected to respond to call lights within five to 10 minutes, and no more than 15 minutes.-á4. Resident 52 was admitted to the facility in 7/2025 with diagnoses including fracture of left leg, anxiety, and difficulty in walking.A 7/16/25 Admission MDS BIMS assessment indicated a score of 13 (cognitively intact).On 8/20/25 at 8:05 AM, Call light computer time log at the nurses station showed Resident 52 activated the call light at 7:45 AM.-á Staff 17 (LPN Charge Nurse) entered the room at 8:06 AM-21 minutes later. At 8:30 AM Staff 17 stated he entered Resident 52's room because the call light had been on for a while. At 8:36 AM Resident 52 stated she had been waiting on the bedside commode, and her/his buttocks were getting sore. Resident 52 reported self-transferring back to bed.On 8/21/25 at 10:58 AM, Staff 14 (CNA) stated she assisted Resident 52 onto the bedside commode on 8/20/25. She then informed other staff by radio she needed to complete a shower for another resident. After finishing the shower, she saw Resident 52's call light was on and again informed staff by radio.-á On 8/22/25 at 12:01 PM, Staff 2 (DNS) stated staff were expected to respond to call lights within five to 10 minutes, and no more than 15 minutes.-á

2. Resident 30 admitted to the facility in 8/2023 with diagnoses including quadriplegia (paralysis in all four limbs) and traumatic brain injury. -áDuring an observation of medication administration on 8/21/25 at 12:25, the Electronic Medication Administration Record (EMAR) used by Staff 20 (CMA) indicated multiple residents were receiving medications later than ordered.-á-áOn 8/21/2025 at 12:45 PM, Staff 19 (LPN) stated he noticed medications were running later than ordered, and he was not sure what the policy was for late medications, or when he was supposed to ask for help.-á-áA review of Resident 30GÇÖs 8/21/25 Medication Administration Audit Report revealed the following: Baclofen 10mg (muscle relaxant) ordered four times a day for muscle spasms:-á- ordered to be given at 7:00 AM and was administered at 12:24 PM by Staff 19 (LPN).- ordered to be given at 12:00 PM and was administered at 1:26 PM by Staff 19 (LPN).- ordered to be given at 4:00 PM and was administered at 3:07 PM by Staff 20 (CMA).-áLevetiracetam 500mg (anti-seizure medication) ordered three times a day for Epilepsy (a seizure disorder):- ordered to be given at 7:00 AM and was administered at 12:24 PM by Staff 19 (LPN).- ordered to be given at 12:00 PM and was administered at 1:26 PM by Staff 19 (LPN).- ordered to be given at 4:00 PM and was administered at 3:07 by Staff 20 (CMA).-áKlonopin 0.5mg (anti-seizure medication) ordered three times a day for Epilepsy:-á- ordered to be given at 7:00 AM and was administered at 12:24 PM by Staff 19 (LPN).- ordered to be given at 12:00 PM and was administered at 1:26 PM by Staff 19 (LPN).- ordered to be given at 4:00 PM and was administered at 3:07 PM by Staff 20 (CMA).-áProgress Notes from 8/21/25 through 8/25/25 revealed no documentation the provider was contacted regarding the med errors, and no alert charting was in the residentGÇÖs medical chart. -á-áOn 8/25/2025 at 9:53 AM, Staff 21 (Pharmacist) stated the Baclofen 10mg, Levetiracetam 500mg, and the Klonopin 0.5mg were not advised to be given so close together. She stated the medications are generally spread out over the waking hours for Resident 30, and the provider should be contacted for orders. She stated these medications administered in close proximity could cause increased lethargy and sedation.-á-áOn 8/25/2025 at 10:21 AM Staff 2 (DNS) stated Staff 19 (LPN) was a new nurse and should not have been administering all the medications by himself. She stated the expectation for staff is to ask for assistance when they need help.-á-áOn 8/25/2025 at 6:07 PM, Staff 25 (Medical Director/Doctor) stated he was aware of the medication errors on 8/21/25. He stated Resident 30 has had violent shaking episodes in the past when her/his medications were not administered on time, and the current medication administration schedule was currently managing her/his seizures. He stated the expectation was for staff to call him for orders when they were late with medication or if a medication dosage was missed.-á-á

The facility Medication Labeling and Storage policy, with unknown publication date, stated multi dose vials were to be dated when opened and discarded within 28 days.-áDuring an observation of the medication storage room on 8/19/25 at 1:18 PM, the following were found:-á- Two bottles of Metamucil (a laxative medication) with an expiration date of 4/2025.-áOn 8/19/25 at 1:34 PM, Staff 22 (LPN) stated the expectation for expired medication was for it to be destroyed and replaced.-áDuring an observation of the Douglas Fir Drive medication cart on 8/19/2025 at 2:04 PM, the following was found: -á- One bottle of acid reducer 20mg (medication used to reduce stomach acid) with an expiration date of 5/2025.-áOn 8/19/2025 at 2:14 PM, Staff 23 (CMA) stated the expectation for expired medication was for it to be removed from the medication cart, destroyed, and replaced. -áDuring an observation of the Douglas Fir Drive treatment cart on 8/19/2025 at 2:17 PM, the following were found: -á- One vial of Insulin Asparte (medication used for diabetes) with an open date of 7/17/25.-á- One vial of Insulin Glargine (medication used for diabetes) with an open date of 7/17/25.-áOn 8/19/2025 at 2:22 PM, Staff 22 (LPN) stated the expectation for insulin was for it to be destroyed 28 days after it was opened and replaced with a new vial.-áOn 8/25/2025 at 10:17 AM, Staff 2 (DNS) acknowledged expired medications were found in the medication storage room, on the Douglas Fir Drive medication cart, and on the Douglas Fir Drive treatment cart. She stated the expectation for expired medications was for them to be destroyed and replaced. She stated insulin was to be destroyed 28 days after being opened and replaced with a new vial.

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On 8/20/25 at 11:04 AM and 8/20/25 at 11:20 AM with Staff 29 (Dietary Manager) the ice machine drainpipe was observed to be in a drain hole with no air gap.-á Staff 29 stated there was no flooding in the kitchen for years.-á-á-áOn 8/21/25 at 12:31 PM Staff 30 (Maintenance) stated in 7/2025 the airgap was identified on a work order to be fixed but was not.-á-áOn 8/25/25 at 10:33 AM Staff 1 (Administrator) stated he was not aware of the lack of airgap for the ice machine prior to survey.-á

Resident 21 admitted to the facility in 6/2025 with diagnoses including nicotine dependency and visual loss.-áThe 6/9/25 Smoking Safety Evaluation revealed Resident 21 was alert and oriented, had visual impairment, and required staff supervision while smoking, including the use of a smoking apron.The 8/6/25 Quarterly MDS revealed Resident 21 had a BIMS of 14, which indicated the resident was cognitively intact.On 8/18/2025 at 1:17 PM, Staff 20 (CMA) assisted Resident 21 to the supervised smoking area. Staff 20 and Staff 33 (CNA) stated no clean smoking aprons were available, as the only remaining apron was moldy. Staff 20 stated he would not want to put a moldy apron on himself, nor would he want to put it on any resident.On 8/18/2025 at 1:19 PM, Staff 33 was told by Staff 2 (DNS) they did not have any more smoking aprons in the facility. The remaining smoking apron was covered in black mold stains. Staff 33 attempted to wipe down the moldy smoking apron with an alcohol-based wipe before placing it on Resident 21. After Staff 33 put the smoking apron on Resident 21 she/he stated, GÇ£yep that smells like mold and alcohol.GÇ¥-áOn 8/18/2025 at 1:22 PM, Staff 33 stated residents should not be wearing moldy smoking aprons.-áOn 8/20/25 at 1:10 PM, Staff 30 (Maintenance Director) stated once he became aware, he replaced all of the smoking aprons. Staff 30 confirmed this was an infection control concern.-á

Based on observation, interview, and record review it was determined the facility failed to ensure resident rooms were cleaned for 1 of 3 sampled residents (#9) reviewed for environment. This placed residents at risk for lack of a homelike environment. Findings include:

Resident 9 admitted to the facility in 2024 with diagnoses including respiratory failure and heart failure.

Review of Resident Council notes for 2/2024 indicated residents reported a lot of dirt on the floors and the floors needed to be swept more.

Observations made from 4/29/24 through 5/1/24 revealed a visible layer of white and gray dust and hairs underneath Resident 9's bed.

Review of the Daily Cleaning Check-Off form indicated Resident 9's room was cleaned on 4/27/24.

On 5/1/24 at 12:24 PM Staff 19 (Housekeeping Manager) stated housekeeping staff cleaned one of three resident halls per day. Staff 9 stated the daily cleaning of resident rooms consisted of cleaning the bathroom, taking out the trash, wiping down high touch areas, sweeping and mopping. Staff 19 stated it was brought to her attention that Resident 9's floor was dirty with dust. Staff 19 acknowledged there was a layer of dust under Resident 9's bed and stated it was, "unacceptable."

Based on interview and record review it was determined the facility failed to protect residents' right to be free from verbal abuse from Staff 24 (RN) for 1 of 1 sampled resident (#20) reviewed for abuse. This placed residents at risk for abuse. Findings include:

The facility's Abuse policy, revised 4/2021, stated the facility and staff would protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including facility staff.

Resident 20 was admitted to the facility in 2023 with diagnoses including major depressive disorder and anxiety disorder.

Resident 20's 2/7/24 Comprehensive MDS indicated the resident was cognitively intact.

Resident 20's 2/26/24 Care Plan indicated the resident was independent with bathing and required set up help only. Resident 20 showered one time per week per the resident's request.

Resident 20's 4/2024 shower logs revealed the resident frequently refused showers.

A 3/31/24 Progress Note indicated Staff 24 (RN) approached Resident 20 in the morning about taking a shower. Resident 20 refused and stated she/he would take a shower after church. After church Staff 24 reapproached Resident 20 about showering and Resident 20 refused again.

On 3/31/24 a Resident/Family Grievance Communication Form completed by Staff 28 (CNA), Staff 29 (CNA), Resident 35 and Resident 20 indicated Staff 24 confronted Resident 20 two times. Per the written statements on the form, Staff 24 stated Resident 20 needed to take a shower before going to church "because she/he stunk".

On 4/29/24 at 12:40 PM Resident 20 stated on 3/31/24, Staff 24 (RN) confronted her/him, in front of Staff 28 (CNA), Staff 29 (CNA) and Resident 35. Staff 24 stated Resident 20 could not go to church unless the resident took a shower first. Resident 20 stated Staff 24 said, "You want people at church to smell you?" Resident 20 stated she/he was upset and the comments made her/him feel terrible.

On 5/1/24 at 12:23 PM Staff 30 (CNA) stated she arrived to work early on 4/29/24 and Staff 24 instructed her to, "make Resident 20 take a shower." Staff 30 stated she would try to get Resident 20 to take a shower. Staff 30 stated after church, she and Staff 24 went into Resident 20's room. Staff 30 stated Resident 20 yelled she/he did not want Staff 24 in the room but Staff 24 would not leave. Staff 30 stated, Staff 24 eventually left the room and Staff 30 observed Resident 20 crying and visibly upset.

The facility's 4/2/24 investigation indicated on 3/31/24 Staff 2 (DNS) was notified Staff 24 was insisting Resident 20 take a shower that morning. Resident 20 refused to take a shower and stated she/he would shower after church. Staff 24 asked the resident, "do you want the church to smell you?" When Resident 20 returned from church, Staff 24 confronted the resident again about taking a shower. Resident 20 stated Staff 24 came to her/his room and yelled at the resident about showering. Resident 20 stated she/he felt it was very rude of Staff 24 and hurt Resident 20's feelings. Resident 20 asked Staff 24 to leave the room and she was escorted out by Staff 30. Staff 28, Staff 29, Staff 30, Staff 31 (LPN) and Resident 35 all indicated Staff 24 yelled at Resident 20 and told her/him "you stink." Staff 24 was terminated on 4/2/24.

On 5/2/24 at 11:40 AM Staff 2 (DNS) stated she spoke with Staff 24 on 3/31/24 about the incident. Staff 2 acknowledged Staff 24 verbally abused Resident 20. Staff 2 stated Staff 24 was terminated after the incident was investigated.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation by Staff 34 (CNA) for 1 of 1 sampled resident (#302) reviewed for misappropriation of personal funds. This placed residents at risk for financial abuse. Findings include:

The facility's revised 4/2021 Abuse, Neglect, Exploitation and Misappropriation Prevention Program stated residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

Resident 302 admitted to the facility in 3/2022 with diagnoses including multiple sclerosis. The 4/2023 Comprehensive MDS identified Resident 302 to be alert and oriented.

On 5/23/23 a Facility Reported Incident was reported indicating Resident 302 bought Staff 34 (CNA) a scrub top (nurse apparel shirt) purchased on-line for $34.00. Resident 302 stated she/he expected Staff 34 to pay her/him back. Staff 34 paid Resident 302 $20.00.

On 5/2/24 at 9:13 AM and at 2:10 PM Staff 34 was unable to be reached via phone.

On 5/2/24 at 9:53 AM Staff 5 (Social Services Director) observed Staff 34 always wore cartoon scrub tops. Staff 5 interviewed Resident 302 and the resident made a comment she/he liked Staff 34's scrub top. Staff 34 said there was a scrub top he wanted to have online but he did not have an account. Resident 302 stated she/he would order it and he agreed he could pay her/him back. Staff 5 stated Staff 34 wore the new scrub top to work and Resident 302 felt disrespected. Staff 34 did not pay Resident 302 the full amount due for the scrub top. Staff 5 stated the facility paid the resident back for the scrub top and Staff 34 was terminated.

On 5/2/24 at 12:16 PM Staff 2 (DNS) and Staff 4 (Corporate RN) stated Resident 302 was reimbursed for the scrub top.

On 5/2/24 at 1:41 PM Resident 302 stated Staff 34 showed her/him a picture of a scrub top online and the resident stated she/he would order it for him. Resident 302 stated on 5/4/23 Staff 34 showed her/him a scrub top online. Resident 302 ordered the scrub top and it was delivered the following day on 5/5/23. Resident 302 stated she/he gave the scrub top to Staff 34 and he wore it. Resident 302 stated she/he begged him to pay the money owed and after some time he paid $20. Resident 302 stated Staff 34 did not pay the remaining balance due for the scrub top and continued to wear the scrub top. Resident 302 stated she/he filed a grievance due to Staff 34 not paying her/him back. Resident 302 stated Staff 2 and Staff 5 stated the facility would pay her/him back, but they never did.

On 5/2/24 at 2:02 PM Staff 35 (Business Office Manager) stated she did not have a receipt for Resident 302's reimbursement for the scrub top.

On 5/2/24 at 2:07 PM Staff 4 acknowledged the misappropriation of the resident's funds and stated there were no receipts for reimbursement to Resident 302. Staff 4 stated staff were not to accept gifts or money from residents.

Based on observation, interview and record review it was determined the facility failed to ensure residents with contractures received ROM services and equipment to prevent further decrease in ROM and skin breakdown for 1 of 1 sampled resident (#4) reviewed for mobility. This placed residents at risk worsening contractures. Findings include:

Resident 4 admitted to the facility on 1/31/24 with diagnoses including quadriplegia and rheumatoid arthritis.

The 2/4/24 admission ADL CAA indicated Resident 4 had impaired ROM and the Care Plan would refer to restorative and/or skilled therapy as appropriate.

Resident 4's clinical record included a copy of a 11/29/21 Care Plan from Resident 4's previous facility. The Care Plan indicated Resident 4 had contractures to her/his bilateral hands and legs related to rheumatoid arthritis. Interventions included the use of palm protectors to be worn during the day.

The 1/31/24 Care Plan revealed no indication of Resident 4's contractures or use of a palm device.

Review of a 3/15/24 OT Evaluation indicated Resident 4 transferred from another facility without therapy orders and a referral was made for contracture management. The evaluation indicated no device was found in Resident 4's room and the resident would benefit from "positioning the left hand, skin protection of the right hand" and the need for a Restorative Aide (RA) program. The evaluation further included the need for a splint and indicated the resident would benefit from ROM to reduce pain, improve skin integrity issues and reduce the risk for further contractures.

On 4/29/24 at 1:28 PM Resident 4 was observed in bed and both of her/his hands were observed to be contracted. Resident 4's nails were trimmed but no palm device was observed in place.

On 4/30/24 at 3:36 PM Resident 4 stated she/he had palm protectors that were worn at the previous facility. Resident 4 stated she/he did not participate in an RA program since she/he admitted to the facility. Resident 4 stated she/he was interested in wearing palm protectors again and participating in RA. Resident 4's right hand palm protector was observed to be in her/his top nightstand drawer.

On 5/2/24 at 10:58 AM Staff 17 (OT) stated she completed the 3/15/24 therapy evaluation for Resident 4. Staff 17 stated RA referrals were completed by filling out the RA form and then discussing it with Staff 15 (Restorative Aide). Staff 17 stated devices such as splints were discussed with the RNCM to determine the device and a schedule for use. Staff 17 stated she saw Resident 4 three times. Staff 17 stated Resident 4 used palm protectors and wore them well. Staff 17 stated Resident 4 went to the hospital on 3/21/24 but was not "picked back up" after she/he returned to the facility on 4/1/24. Staff 17 acknowledged no RA referral was completed for Resident 4 and there was no follow-up regarding the recommended use of a palm device.

On 5/2/24 at 11:18 AM Staff 15 stated Resident 4 was not on the RA list, and he never received a referral for Resident 4 to participate in the RA program.

On 5/2/24 at 12:17 PM Staff 3 (RNCM) stated Resident 4 transferred from another facility. Staff 3 stated Resident 4 was compliant with care, but had very fragile skin, and was prone to skin tears and bruising that required extra monitoring. Staff 3 stated Resident 4 also had contractures to both hands. Staff 3 stated Resident 4 had an OT evaluation completed but was, "unsure what came of it." Staff 4 acknowledged no follow up was completed regarding the 3/15/24 OT recommendations and acknowledged she was not aware Resident 4 was not being seen by RA.

Based on interview and record review it was determined the facility failed to assess falls and provide treatment to prevent falls for 1 of 1 sampled resident (#25) reviewed for accidents. This placed residents at risk for falls and injuries. Findings include:

Resident 25 admitted to the facility in 2022 with diagnoses including weakness and heart failure.

The 1/26/24 Annual MDS indicated Resident 25 was cognitively intact.

On 4/29/24 at 1:31 PM Resident 25 stated she/he fell out of the "sit-to-stand" (a device used to transfer residents between seated to standing positions) several months ago.

On 4/30/24 Resident 25's clinical record was reviewed. No fall assessments or incident reports were found.

On 4/30/24 a fall assessment was requested from Staff 2 (DNS).

On 4/30/24 at 10:31 AM Staff 2 (DNS) stated Resident 25 did not have a fall from the sit-to-stand device, but was assisted to the floor by staff and stated, "So it wasn't a fall." Staff 2 stated no assessment was completed.

On 5/1/24 at 2:12 PM Staff 2 provided a written statement dated 5/1/24 from Staff 20 (CNA) that indicated, "At around 8 PM myself and another CNA [were] laying a resident down with a sit-stand, when [her/his] legs seemed to give out. One of us was in front of [her/him], when [her/his] legs seemed to give out. I was behind [her/him] so was able to guide [her/him] by sliding [her/him] down my right leg. Then we used a [mechanical] lift to put [her/him] on the bed, resident had no claims of pain." The date of the incident was not noted on the witness statement.

On 5/1/24 at 3:55 PM Staff 2 provided a statement that Staff 20 noted the incident with Resident 25 happened on the approximate date of 2/19/24 but could not recall the exact date.

On 5/1/24 at 2:25 PM Resident 25 stated she/he fell on her/his hip and back but did not remember the date. Resident 25 stated Staff 20 and another staff assisted her/him with the sit-to-stand. Resident 25 stated she/he fell to the floor on her/his left hip, hit the floor, and laid on the floor on her/his side. Resident 25 stated staff had to use a mechanical lift to get her/him off the floor and back into bed. Resident 25 stated Witness 3 (Family Member) was present at the time of the fall.

On 5/1/24 at 2:33 PM Witness 3 stated Resident 25 had a fall about a month prior. The resident was on the edge of the bed, slid down the CNA's leg, landed on the floor, and was scared. Witness 3 stated it happened so fast and it also scared him when it happened. Witness 3 stated he did not like the sit-to-stand device that was used because the way staff had to maneuver the resident with the gait belt was difficult, especially if the staff using it were not strong. Witness 3 stated the other CNA who assisted looked like she was confused when using the sit-to-stand device. Witness 3 stated staff used a mechanical lift to assist the resident off the floor and back to bed after the fall.

On 5/1/24 at 2:45 PM training logs were requested from Staff 14 (Director of Rehab) for Resident 25's sit-to-stand device.

On 5/1/24 at 3:59 PM and 5/2/24 at 10:06 AM messages were left for Staff 20. A return call was not received.

On 5/1/24 at 4:07 PM Staff 14 stated Staff 15 (Restorative Aide) was the only staff who was supposed to use the sit-to-stand device with Resident 25. Staff 14 acknowledged other staff were not trained to use the sit-to-stand device for Resident 25.

On 5/2/24 at 2:03 AM Staff 21 (LPN) stated she worked on 3/1/24 when Resident 25 had a fall, but did not witness it. Staff 21 stated Staff 20 and Staff 8 (CNA) reported they assisted the resident with the sit-to-stand when the resident fell to the ground. Staff 21 stated she started an incident report and then reported the incident to Staff 2. Staff 21 stated the expectation was to get witness statements for incident reports and she thought she had the staff's written statements but was unable to locate them in the clinical record. Staff 21 stated the incident report was "struck out" and did not have information regarding the incident.

On 5/2/24 at 12:27 PM Staff 3 (RNCM) stated she was not aware of a fall or incident for Resident 25. Staff 3 reviewed the medical record and stated an incident report was started on 3/1/24 and was blank. Staff 3 stated Staff 2 struck out the incident report on 3/6/24 due to "incorrect documentation."

On 5/2/24 at 12:38 PM Staff 8 stated she was present for Resident 25's fall on 3/1/24. Staff 8 stated she wrote a statement and provided it to the facility. Staff 8 stated Staff 20 showed her how to use the sit-to-stand transfer device on 3/1/24. Staff 8 stated Resident 25 claimed she/he could use the device, but her/his knees were too weak to use it. Staff 8 stated the resident was sitting in her/his wheelchair and was assisted to get up, but her/his legs got "wobbly." Staff 8 stated the resident had a gait belt on and, "We brought [her/him] down to the ground onto the floor." Staff 8 stated the resident was anxious after the incident and only wanted "bigger staff" to use the device with her/him.

On 5/2/24 at 1:19 PM and on 5/3/24 at 9:10 AM Staff 2 stated staff did not report Resident 25's fall but she found out about it through an "unrelated grievance." The findings were reviewed with Staff 2 regarding the incident report that Staff 21 opened on 3/1/24 at 10:00 PM. Staff 2 stated she struck out the incident report on 3/6/24 because there was no information in the report. Staff 2 acknowledged Resident 25 had a fall on 3/1/24, it was not investigated and interviews were not completed with Staff 21, Staff 20 and Staff 8 who worked with Resident 25 on 3/1/24. Staff 2 further acknowledged Staff 20 and Staff 8 did not receive the appropriate training for using the sit-to-stand device for Resident 25.

Based on observation, interview, and record review it was determined the facility failed ensure oxygen was administered as ordered and maintain oxygen concentrators for 2 of 3 sampled residents (#s 36 and 251) reviewed for oxygen therapy. This placed residents at risk for increased risk for respiratory failure. Findings include:

1. Resident 36 was admitted to the facility in 8/2023 with diagnoses including chronic respiratory failure with hypercapnia (buildup of carbon dioxide in the bloodstream).

The 1/15/24 Significant Change MDS indicated Resident 36 was moderately cognitively impaired.

Multiple observations from 4/29/24 through 5/1/24 revealed Resident 36 used an oxygen concentrator. The external filter on the oxygen concentrator was observed to have a layer of dust when touched with a finger.

Resident 36's physicians order dated 4/2/24 indicated:
- clean external filter on the oxygen concentrator every Tuesday on night shift.

The 4/2024 TAR indicated on 4/23/24 the external filter on the oxygen concentrator was cleaned by Staff 21 (LPN) who worked the night shift.

On 4/29/24 at 12:34 PM Resident 36 stated she/he wore oxygen continuously.

On 5/1/24 at 12:17 PM Resident 36's oxygen concentrator's external filter was observed to have no change in appearance.

On 5/1/24 at 2:23 PM and 2:41 PM Staff 12 (LPN) and Staff 13 (LPN) both stated the night shift nurses were responsible for cleaning Resident 36's oxygen concentrator filter.

On 5/1/24 at 2:56 PM a phone call and voicemail were placed to Staff 21 with no return phone call.

On 5/1/24 at 3:32 PM Staff 2 (DNS) observed the oxygen concentrator's external filter and acknowledged the filter was not clean.

2. Resident 251 was admitted to the facility in 2/2024 with diagnoses including acute respiratory failure with hypoxia (not enough oxygen in the tissues in your body) and dementia.

The 3/1/24 Significant Change MDS indicated Resident 251 was moderately cognitively impaired.

Observations from 4/29/24 through 5/1/24 revealed Resident 251 used an oxygen concentrator with a nasal cannula (lightweight tubing with two prongs placed in nostrils) with a flow rate of three liters of oxygen. The external filter on the oxygen concentrator was observed to have a layer of dust when touched with a finger.

Resident 251's physicians order dated 4/2/24 indicated:
- oxygen at one to two liters per minute via a nasal cannula as needed for shortness of breath.

The 4/2024 TAR did not indicate when the external filter on the oxygen concentrator was to be cleaned.

On 4/29/24 at 12:44 PM Resident 251 stated she/he used oxygen but could not state when she/he used it or how many liters were prescribed.

On 5/1/24 at 2:23 PM Staff 12 (LPN) stated the resident used oxygen as needed and the physician order stated one to two liters per minute for the flow rate. Staff 12 further stated night shift nurses were responsible for cleaning Resident 251's oxygen concentrator.

On 5/1/24 at 3: 21 PM Staff 2 (DNS) stated Resident 251 had a physicians order for oxygen therapy as needed at a flow rate of one to two liters per minute.

On 5/1/24 at 3:32 PM Staff 2 observed and acknowledged the physician order was not followed regarding the oxygen flow rate and the external filter of the oxygen concentrator was not clean.

Based on interview and record review it was determined the facility failed to follow pharmacist recommendations in a timely manner for 1 of 5 sampled residents (#30) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication administration. Findings include:

Resident 30 admitted to the facility in 2023 with diagnoses including major depressive disorder and psychosis.

The 1/16/24 pharmacist recommendation indicated Resident 30 did not display psychotic behavior but had issues with depression, and to consider an order to increase nortriptyline (antidepressant) to 50 mg daily at bedtime for depression and to decrease aripiprazole (antipsychotic) to 2 mg daily for psychosis.

The pharmacist recommendation was not signed by the physician until 2/4/24 (19 days after the recommendation was made). The physician recommendation included to discontinue nortriptyline and start Lexapro (antidepressant) 5 mg daily.

On 5/1/24 at 2:12 PM Staff 2 (DNS) stated the expectation was for pharmacist recommendations to be reviewed and signed by the physician within 7 days. Staff 2 acknowledged Resident 53's pharmacist recommendations were not completed until 19 days after the recommendation was made, which was not timely.

Based on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals, and failed to ensure proper storage temperatures were logged and maintained for 2 of 2 treatment carts and 1 of 1 medication room reviewed for medication storage. This placed residents at risk for reduced efficacy of medication and adverse medication side effects. Findings include:

1. On 5/1/24 at 3:20 PM two vials of tuberculin (used for the testing in the diagnosis of Tuberculosis) were observed to be opened; one was dated October of an illegible year and another was dated 3/22/24. The manufacturer's instructions indicated to discard the medication 30 days after opening.

On 5/1/24 at 3:20 PM Staff 12 (LPN) acknowledged the two vials of tuberculin were opened and expired.

2. On 5/1/24 at 3:20 PM the medication refrigerator temperature logs were observed to be blank on 4/1/24, 4/2/24, and 4/4/24 through 4/30/24.

On 5/1/24 at 3:20 PM Staff 12 (LPN) acknowledged the temperature logs were blank on 4/1/24, 4/2/24 and 4/4/24 through 4/30/24.

3. On 5/1/24 at 3:28 PM the treatment cart for the 100 hall was observed to have one Admelog insulin vial with an open date of 3/22/24. Per manufacturer instructions Admelog insulin was good for 28 days after opening (expired on 4/19/24).

On 5/1/24 at 3:28 PM Staff 8 (LPN) acknowledged the Admelog insulin vial was expired.

4. On 5/1/24 at 3:28 PM the treatment cart for the 100 hall was observed to have one Novolog insulin vial with an open date of 3/20 (no year was documented). Per manufacturer instructions Novolog insulin was good for 28 days after opening (expired on 4/17/24).

On 5/1/24 at 3:28 PM Staff 8 (LPN) acknowledged the Novolog insulin vial was expired.

Based on observation, interview, and record review it was determined the facility failed to handle and prepare food in a sanitary manner for 1 of 1 kitchen reviewed for sanitary practices. This placed residents at risk for food borne illness. Findings include:

On 5/2/24 at 11:48 AM Staff 26 (Cook/Dietary Aide) was observed to cut a hamburger patty with gloved hands on the cutting board attached to the steam table. Staff 26 placed the hamburger patty on a plate. Staff 26 then grabbed a rag from the red bleach bucket and wiped the cutting board and knife. The cutting board was observed to still be wet when Staff 26 used the same gloved hands to grab a skinned baked potato and cut it on the wet cutting board with the same knife.

On 5/2/24 at 11:50 AM when asked about the drying time after wiping a surface, Staff 26 stated she, "had no idea." When asked when it was appropriate to change gloves, Staff 26 stated she changed gloves often and had a box of gloves next to her work surface. When asked why she did not change her gloves after using the rag from the bleach bucket and before touching food, Staff 26 stated, "I should have changed my gloves, but I forgot."

On 5/3/24 at 9:19 AM Staff 27 (Dietary Manager) stated she expected staff to change their gloves and perform hand hygiene whenever they touched a potentially contaminated surface area to minimize risk of food borne illness, and expected staff to use portable cutting boards and to change out the cutting boards when needed.

Based on interview and record review it was determined the facility failed to have a dialysis agreement in place for 1 of 1 sampled resident (#45) reviewed for dialysis. This placed residents at risk for not receiving dialysis services. Findings include:

Resident 45 admitted to the facility in 4/2024 with diagnoses including dependence on renal dialysis.

On 4/30/24 a copy of the dialysis agreement was requested from Staff 4 (Corporate RN).

On 4/30/24 at 1:52 PM Staff 4 stated the facility did not have a dialysis agreement in place for Resident 45.

Based on interview and record review it was determined the facility failed to accurately document medication administration for 1 of 4 sampled residents (#33) reviewed for physician orders. This placed residents at risk for inaccurate medical records. Findings include:

Resident 33 admitted to the facility in 3/2024 with diagnoses including hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs) and septic arthritis (an infection in the joint fluid and tissues).

a. A physician order dated 4/1/24 instructed staff to administer one tablet of levothyroxine 50mcg (a thyroid medication) one time a day at 5:00 AM.

A review of Resident 33's April 2024 MAR revealed the resident did not receive the scheduled dose on 4/26/24 at 5:00 AM. There were no progress notes in the resident's clinical record to indicate the reason for the missed dose.

On 5/2/24 at 1:50 PM Staff 3 (RNCM) stated the documentation for 4/26/24 on the MAR was inaccurate. Staff 3 stated she contacted Staff 32 (LPN) on 5/2/24 and Staff 32 indicated Staff 32 administered levothyroxine 50 mcg to Resident 33 and forgot to document in the clinical record.

b. A physican order dated 4/22/24 instructed staff to administer vancomycin solution 250 ml (an antibiotic) intravenously (into the vein) two times a day at 11:00 AM and 11:00 PM.

A review of Resident 33's April 2024 TAR revealed the resident did not receive the scheduled dose of vancomycin solution 250 ml on 4/26/24 at 11:00 AM. There were no progress notes in the resident's clinical record to indicate the reason for the missed dose.

On 5/2/24 at 1:50 PM Staff 3 (RNCM) stated the documentation for 4/26/24 on the TAR was inaccurate. Staff 3 stated she contacted Staff 33 (LPN) on 5/2/24 and Staff 33 administered vancomycin solution 250 ml intravenously to Resident 33 and forgot to document in the clinical record.

Based on interview and record review it was determined the facility failed to process laundry to produce hygienically clean laundry and prevent the spread of infection for 1 of 1 laundry room reviewed for infection control. This placed residents at risk for contaminated laundry. Findings include:

According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D, damp laundry was not to be left in machines overnight.

On 5/1/24 at 1:17 PM Staff 22 (Housekeeping) stated her shift ended at 2:00 PM and she had the last shift of the day. Staff 22 stated when wet laundry was not completed in the washing machine at the end of her shift, she left the wet laundry in the washing machine overnight. Staff 22 stated the next morning she transferred the wet laundry to the dryer and did not rewash the laundry.

On 5/2/24 at 8:52 AM Staff 23 (Housekeeping) stated her shift ended at 2:00 PM and she had the last shift of the day. Staff 23 stated multiple times a week she left wet laundry in the washing machine overnight and transferred the wet laundry to the dryer the next morning. She stated she did not rewash the laundry before it was transferred to the dryer. Staff 23 further stated when the dryer cycle was not completed at the end of her shift, she placed the damp laundry in a basket and covered it. The next morning, she then placed the damp laundry back into the dryer to finish the drying process.

On 5/2/24 at 10:15 AM Staff 19 (Housekeeping Manager) was informed of the findings. She acknowledged the staff did not follow standards to produce hygienically clean laundry.

Based on interview and record review it was determined the facility failed to ensure residents were offered a pneumonia vaccine for 1 of 5 sampled residents (#30) reviewed for immunizations. This placed residents at risk for infections. Findings include:

The facility's Pneumococcal Vaccine Policy dated 3/2022 indicated, "assessments of pneumococcal vaccination status are conducted within five working days of the resident's admission if not conducted prior to admission."

Resident 30 admitted to the facility in 8/2023 with diagnoses including depression.

A review of Resident 30's clinical record revealed she/he did not receive a pneumonia vaccine and there was no indication the resident was offered a pneumonia vaccine upon admission to the facility.

On 5/2/24 at 1:30 PM Staff 18 (IP) stated upon admission a resident was to be offered vaccinations if eligible, including the pneumonia vaccine. Staff 18 confirmed Resident 30 was not offered the pneumonia vaccine upon admission.

Based on interview and record review it was determined the facility failed to ensure reference checks were completed for 5 of 5 newly hired facility staff (#s 7, 8, 9, 10 and 11). This placed residents at risk for abuse. Findings include:

On 4/30/24 at 11:20 AM the facility submitted a list of newly hired staff, including:

1. Staff 7 (CNA) hired on 12/30/23.
2. Staff 8 (CNA) hired on 1/23/24.
3. Staff 9 (RN) hired on 2/9/24.
4. Staff 10 (CNA) hired on 3/12/24.
5. Staff 11 (CMA) hired on 4/3/24.

There was no evidence reference checks were completed for the identified staff.

On 4/30/24 at 1:49 PM Staff 6 (Human Resources Director) stated he did not complete reference checks for new hires.

On 5/1/24 at 3:19 PM Staff 1 (Administrator) acknowledged the findings. No additional information was provided.

OAR 411-087-0100 Physical Environment: Generally

Refer to F584
***********
OAR 411-085-0360 Abuse

Refer to F600 and F602
***********
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F695
***********
OAR 411-086-0150

Refer to F688
***********
OAR 411-086-0260 Pharmaceutical Services

Refer to F756 and F761
***********
OAR 411-086-0250 Dietary Services

Refer to F812
***********
OAR 411-086-0110 Administrator

Refer to F840
***********
OAR 411-086-0300 Clinical Records

Refer to F842
***********
OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880
***********
OAR 411-0140 Nursing Services: Problem Resolution & Preventative Care

Refer to F689 and F883
***********

Based on interview and record review it was determined the facility failed to ensure Staff 3 (RN) and Staff 4 (LPN) adhered to professional standards of practice related to the provision of CPR (cardiopulmonary resuscitation) on a resident found with no heartbeat and not breathing for 1 of 1 sampled resident (#1) reviewed for Death/CPR. This failure, determined to be an immediate jeopardy situation, resulted from the failure to initiate CPR for the resident according to physician's orders. This failure prevented the possible resuscitation and continued life of Resident 1.
Findings include:

OAR 8510450040 "Scope of Practice Standards for All Licensed Nurses" indicated the following:
(1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse:
(b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering.

OAR 8510450050 "Scope of Practice Standards for Licensed Practical Nurses" indicated the following:
(2) Standards related to the Licensed Practical Nurse's responsibility for nursing practice implementation. Under the clinical direction of the RN or other licensed provider who has the authority to make changes in the plan of care, and applying practical nursing knowledge drawn from the biological, psychological, social, sexual, economic, cultural, and spiritual aspects of the client's condition or needs, the Licensed Practical Nurse shall:
(C) Selecting appropriate nursing interventions and strategies,
(d) Implement the plan of care.

OAR 8510450070 "Conduct Derogatory to the Standards of Nursing Defined" indicated the following:
Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following:
(1) Conduct related to the client's safety and integrity:
(b) Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment.
(3) Conduct related to communication:
(h) Failing to communicate information regarding the client's status to members of the health care team (physician, nurse practitioner, nursing supervisor, nurse coworker) in an ongoing and timely manner.

Resident 1 was admitted to the facility in 2022 with diagnoses including Type 2 Diabetes and late onset Alzheimer's disease.

Resident 1's care plan dated 8/19/22 included "Advance Directives Full Code (CPR)" and the resident's POLST (Portable Orders for Life-Sustaining Treatment) was on file with the facility.

Resident 1's POLST dated 8/19/22 indicated the resident's code status was "Full Code" (meaning the resident desired intervention such as CPR should her/his heart stop beating or she/he stops breathing) and "Full Treatment" (use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated).

1. A facility Final Investigation dated 11/14/23 indicated on 11/8/23 at 5:50 AM Resident 2 (roommate) of Resident 1 heard the resident coughing and asking for help. Resident 2 went into the hallway and requested help from Staff 6 (CNA). Staff 7 (CNA) also responded. The two CNAs adjusted the resident's position and brought the resident some ice water. Staff 6 said the resident told her she felt better.
At 6:20 AM Resident 2 called to Resident 1 but received no response. Resident 2 again went out to the hallway and got assistance from Staff 5 (CNA) who determined the resident had no pulse and called for the nurse. Staff 3 (RN) and Staff 4 (LPN)responded to the room. The resident was pale gray and unresponsive. The investigation noted Staff 3 felt the resident had been expired too long. Staff 4 verified the resident was a Full Code. A Code Blue was not called, the crash cart was not brought to the room, CPR was not initiated, and 911 was not called. Staff 4 left the facility because it was the end of her shift and she was not scheduled for another shift for a few days. Staff 3 was suspended pending an investigation.

The facility Final Investigation dated 11/14/23 also included a written statement from Staff 3 (RN) dated 11/8/23. The statement indicated Staff 3 followed Staff 4 (LPN) to Resident 1's room when Staff 5 (CNA) called for assistance. They entered the room and Resident 1 was lying in bed not breathing with no pulse. The resident was pale gray in color, warm to the touch but they were unable to arouse her/him. No other information was included in the statement related to anything which occurred after they found the resident unresponsive.

On 11/17/23 at 10:34 AM Staff 3 (RN) indicated on 11/8/23 he and Staff 4 responded to Staff 5's (CNA) radio call for a nurse to come to Resident 1's room. They went to the resident's room and the resident was dead. Staff 3 said he had not finished report yet so he "was not really prepared for work". Resident 1 was not breathing, had no pulse, and was colorless. Staff 3 then walked back out of the room and did not return to the room. Staff 3 said he did not know the code status of the resident and did not think to look in the code book. Staff 3 stated he should have checked the code status of the resident, called a Code Blue (resident with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a facility-wide alert), got the crash cart, started CPR, called the ambulance, and sent the resident to the hospital. Staff 3 also said he did not do what he should have done and did not follow procedure, he "messed up".

On 11/17/23 at 11:48 AM Staff 2 (DNS) indicated she was notified by Staff 4 of the resident's death but was unaware at the time that the nurses had not followed all the appropriate procedures for finding a resident unresponsive. She assumed, since both nurses had many years of experience, they had followed standards of practice related to finding the resident unresponsive. It was her expectation that when a resident was found unresponsive, and was a Full Code, staff would call a Code Blue to get assistance, get the crash cart, start CPR, verify the resident's code status, call 911 and send the resident to the hospital if needed. That did not happen for this incident.

2. On 11/17/23 at 10:06 AM Staff 4 (LPN) said on 11/8/23 she responded to Staff 5's (CNA) call for a nurse to come to Resident 1's room. She went into the room with Staff 3 (RN). The resident was not breathing and her/his color was "grayish". They did not know the resident's code status and left the room to determine the status. The resident was a Full Code. They did not return to the resident's room. They did not call a Code Blue (resident with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a facility-wide alert), they did not do CPR, and they did not call 911. Staff 4 said she did not know why she did not start CPR but she should have, even if the RN did not. Staff 4 acknowledged she knew what steps to take when a resident was unresponsive, but failed to follow procedure for the resident who was unresponsive and who's code status was FULL Code which included CPR.

A facility Final Investigation dated 11/14/23 included a written statement from Staff 4 dated 11/8/23 at 6:20 AM which indicated Staff 5 called Staff 4 to Resident 1's room. Staff 3 went with her and they entered the room. The resident was sitting up in bed with no respirations or pulse. The resident's POLST was verified. Staff 4 called the DNS, the resident's family, and the funeral home. Staff 3 said he would call the doctor. Postmortem care was provided to Resident 1 by CNA staff. No information was contained in the statement related to what steps were taken when they found the resident unresponsive or why CPR was not initiated.

On 11/17/23 at 11:48 AM Staff 2 (DNS) indicated she was notified by Staff 4 of the resident's death but was unaware at the time that the nurses had not followed all the appropriate procedures for finding a resident unresponsive. She assumed, since both nurses (Staff 3 and Staff 4) had many years of experience, they had followed standards of practice related to finding the resident unresponsive. It was her expectation that when a resident was found unresponsive, and was a Full Code, staff would call a Code Blue to get assistance, get the crash cart, start CPR, verify the resident's code status, call 911 and send the resident to the hospital if needed. That did not happen for this incident.

On 11/17/23 at 5:02 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified the incident on 11/8/23 was an Immediate Jeopardy situation. As the facility identified the deficient practice and instituted corrections, this was determined to qualify for the designation as past non-compliance.

On 11/18/23 at 7:28 AM the facility provided their immediacy removal plan. The facility identified non-compliance on 11/8/23, initiated training, and education with staff which was completed on 11/14/23. The plan included the following:

1. DNS completed immediate huddle with current floor staff on 11/8/23.
2. An audit of the facility was completed to determine all residents' code status.
3. DNS (or designee) completed training for direct care staff. Completion date 11/14/23. Trainings included the following:
        
a.      
Expectations of care for unresponsive resident.
        
b.      
Performance of duties when a code blue is called.
        
c.      
Policy for Emergency Procedure of CPR.
        
d.      
Location of POLST Binder related to obtaining Code status information.
4. Completion of mock code blue drills for each shift: Completed 11/14/23.
5. Monitoring: Audits for code status initiated beginning 11/14/23 including:
        
a.      
POLST Binder
        
b.      
Electronic Health Record (EHR) for accuracy
        
c.      
Orders in EHR for change
        
d.      
Plan of Care in EHR
weekly for four weeks, then monthly for four months for compliance and as needed thereafter. All findings would be reviewed in QAPI until significant compliance was met.
6. DNS (or designee) audited employee status for:
        
a.      
CPR certification
        
b.      
Latest training and review of policy & procedure, and implementation of Code Blues.
        
c.      
Mock Code Blue drill participation
weekly for four weeks, then monthly for four months, for compliance and as needed thereafter. All findings would be reviewed in QAPI until significant compliance was met.

On 11/16/23 at 2:45 PM Survey determined the Past Non-Compliance was corrected on 11/14/23 when the facility identified deficient practice, initiated corrections, and completed staff education and training. This included:
1. A review of the facility's audit tool used to determine residents' code status.
2. A review of facility In-Service Training Reports regarding the facility policy on code status and emergency CPR, Code Blues, Mock Code Skills, and Emergency Crash Carts with staff signatures for attendance.
3. Interviews with CNA and licensed nurse staff to verify they were provided the in-service trainings and could accurately explain emergency procedures.

Based on interview and record review it was determined the facility failed to perform CPR (Cardiopulmonary Resuscitation) on a resident found with no heartbeat and not breathing for 1 of 1 sampled residents (#1) reviewed for Death/CPR. This failure, determined to be an immediate jeopardy situation, resulted from the facility failing to initiate CPR for Resident 1 according to physician's orders. This failure prevented the possible resuscitation and continued life of Resident 1. Without immediate action to correct the failure the 19 other full code residents at the facility were at risk for not being resuscitated. Findings include:

Resident 1 was admitted to the facility in 2022 with diagnoses including Type 2 Diabetes and late onset Alzheimer's disease.

Resident 1's care plan dated 8/19/22 included "Advance Directives Full Code (CPR)" and the resident's POLST (Portable Orders for Life-Sustaining Treatment) was on file with the facility.

Resident 1's POLST dated 8/19/22 indicated the resident's code status was "Full Code" (meaning the resident desired intervention such as CPR should her/his heart stop beating or she/he stops breathing) and "Full Treatment" (use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated).

A review of the facility's Policy Information for Code Blue (resident with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a facility-wide alert) initiation dated 11/8/23 included the following:
1. If a resident was unresponsive, briefly assess and call for help.
2. Begin CPR-instruct staff member to call a Code Blue and initiate call to 911.
3. Verify, or instruct staff member to verify, the resident's POLST for code status.

A facility Final Investigation dated 11/14/23 indicated on 11/8/23 at 5:50 AM Resident 2 (Roommate) of Resident 1 heard the resident coughing and asking for help. Resident 2 went into the hallway and requested help from Staff 6 (CNA) and Staff 7 (CNA) also responded. The two CNAs adjusted the resident's position and brought the resident some ice water. Staff 6 said the resident told her she felt better.
At 6:20 AM Resident 2 called to Resident 1 but received no response. Resident 2 again went out to the hallway and got assistance from Staff 5 (CNA) who determined the resident had no pulse and called for the nurse. Staff 3 (RN) and Staff 4 (LPN) responded to the room. The resident was pale gray and unresponsive. The investigation noted Staff 3 felt the resident had been expired too long. Staff 4 verified the resident was a Full Code. Code Blue status was not called, the crash cart was not brought to the room, CPR was not initiated, and 911 was not called. Staff 4 left the facility because it was the end of her shift and she was not scheduled for another shift for a few days. Staff 3 was suspended pending an investigation.

The facility Final Investigation dated 11/14/23 included a written statement from Staff 3 dated 11/8/23. The statement indicated Staff 3 followed Staff 4 to Resident 1's room when the CNA called for assistance. They entered the room and the resident was lying in bed not breathing with no pulse. The resident was pale gray in color, warm to the touch and they were unable to arouse her/him.

The facility Final Investigation dated 11/14/23 included a written statement from Staff 4 dated 11/8/23 at 6:20 AM which indicated Staff 5 called Staff 4 to Resident 1's room. Staff 3 went with her and they entered the room. The resident was sitting up in bed with no respirations or pulse. The resident's POLST was verified. Staff 4 called the DNS, the resident's family, and the funeral home. Staff 3 said he would call the doctor. Postmortem care was provided to Resident 1 by CNA staff. No information was contained in the statement related to what steps were taken when they found the resident unresponsive or why CPR was not initiated.

On 11/17/23 at 10:06 AM Staff 4 said she responded on 11/8/23 to Staff 5's radio call for a nurse to Resident 1's room. She went into the room with Staff 3. The resident was not breathing and her/his color was "grayish". They did not know the resident's code status and left the room to determine the status. The resident was a Full Code but they did not return to the resident's room. They did not call a Code Blue, start CPR, or call 911. Staff 4 said she did not know why she did not start CPR but she should have, even if the RN did not. Staff 4 acknowledged she knew what steps to take when a resident was unresponsive, but failed to follow procedure for the resident who was unresponsive and who's code status was Full Code which included CPR.

On 11/17/23 at 10:34 AM Staff 3 indicated on 11/8/23 he and Staff 4 responded to Staff 5's radio call for a nurse to come to Resident 1's room. They went to the resident's room and the resident was dead. Staff 3 said he had not finished report yet so he "was not really prepared for work". Resident 1 was not breathing, had no pulse, and was colorless. Staff 3 then walked back out of the room and did not return to the room. Staff 3 said he did not know the code status of the resident and did not think to look in the code book. Staff 3 stated he should have checked the code status of the resident, started CPR, called the ambulance, and sent the resident to the hospital. Staff 3 also said he did not do what he should have done and did not follow procedure, he "messed up".

On 11/17/23 at 11:48 AM Staff 2 (DNS) indicated she was notified by Staff 4 of the resident's death but was unaware at the time that the two nurses involved had not followed all the appropriate procedures for finding a resident unresponsive. She assumed, since both nurses had many years of experience, they had followed standards of practice related to finding the resident unresponsive. It was her expectation that when a resident was found unresponsive, and was a Full Code, staff would call a Code Blue to get assistance, get the crash cart, start CPR, verify the resident's code status, call 911 and send the resident to the hospital if needed. That did not happen for this incident.

On 11/17/23 at 5:02 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified the incident on 11/8/23 was an Immediate Jeopardy situation. As the facility identified the deficient practice and instituted corrections, this was determined to qualify for the designation as past non-compliance.

On 11/18/23 at 7:28 AM the facility provided their immediacy removal plan. The facility identified non-compliance on 11/8/23, initiated training, and education with staff which was completed on 11/14/23. The plan included the following:

1. DNS completed immediate huddle with current floor staff on 11/8/23.
2. An audit of the facility was completed to determine all residents' code status.
3. DNS (or designee) completed training for direct care staff. Completion date 11/14/23. Trainings included the following:
        
a.      
Expectations of care for unresponsive resident.
        
b.      
Performance of duties when a code blue is called.
        
c.      
Policy for Emergency Procedure of CPR.
        
d.      
Location of POLST Binder related to obtaining Code status information.
4. Completion of mock code blue drills for each shift: Completed 11/14/23.
5. Monitoring: Audits for code status initiated beginning 11/14/23 including:
        
a.      
POLST Binder
        
b.      
Electronic Health Record (EHR) for accuracy
        
c.      
Orders in EHR for change
        
d.      
Plan of Care in EHR
weekly for four weeks, then monthly for four months for compliance and as needed thereafter. All findings would be reviewed in QAPI until significant compliance was met.
6. DNS (or designee) audited employee status for:
        
a.      
CPR certification
        
b.      
Latest training and review of policy & procedure, and implementation of Code Blues.
        
c.      
Mock Code Blue drill participation
weekly for four weeks, then monthly for four months, for compliance and as needed thereafter. All findings would be reviewed in QAPI until significant compliance was met.

On 11/16/23 at 2:45 PM Survey determined the Past Non-Compliance was corrected on 11/14/23 when the facility identified deficient practice, initiated corrections, and completed staff education and training. This included:
1. A review of the facility's audit tool used to determine residents' code status.
2. A review of facility In-Service Training Reports regarding the facility policy on code status and emergency CPR, Code Blues, Mock Code Skills, and Emergency Crash Carts with staff signatures for attendance.
3. Interviews with CNA and licensed nurse staff to verify they were provided the in-service trainings and could accurately explain emergency procedures.

*********************
OAR 411-086-0110 Nursing Services: Resident Care


Refer to F658
*********************
OAR 411-086-0120 Nursing Services: Change of condition


Refer to F678
*********************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/14/2023 and 08/20/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation, interview and record review it was determined the facility failed to ensure call lights were within reach for 2 of 2 sampled residents (#s 19 and 30) reviewed for call lights. This placed residents at risk for unmet needs. Findings include:

1. Resident 19 admitted to the facility in 2021 with diagnoses including Parkinson's disease (a brain disorder that affects movement).

On 3/7/23 at 9:54 AM Resident 19 stated her/his call light was not always placed where she/he could reach it.

On 3/8/23 at 11:18 AM Resident 19 was lying in bed. The call light was on the recliner behind the head of the bed. Resident 19 stated she/he could not reach the call light.

On 3/8/23 at 11:24 AM Staff 3 (LPN-RCM) confirmed Resident 19's call light was on the recliner and Resident 19 would not be able to reach the call light. Staff 3 stated staff were expected to keep call lights in resident's reach.

On 3/9/23 at 10:47 AM Staff 2 (DNS) confirmed call lights were expected to always be within residents' reach.

2. Resident 30 admitted to the facility in 2021 with diagnoses including dementia.

On 3/8/23 at 4:03 PM Resident 30 sat in her/his wheelchair, her/his call light was hanging off the handles on the back of the wheelchair. Staff 29 (CNA) stated Resident 30's call light was not in reach but should be within reach.

On 3/9/23 at 10:47 AM Staff 2 (DNS) confirmed the call lights were expected to be within residents' reach.

On 3/9/23 at 3:01 PM Resident 30 was lying in bed slightly on her/his left, her/his call light was observed under the right side of her/his pillow. Staff 28 (CNA) verified Resident 30's call light was not in reach but should be within reach.

Based on observation, interview and record review it was determined the facility failed to ensure comfortable temperatures were maintained in all areas of the facility for 1 of 1 facility. This placed residents at risk for an uncomfortable environment. Findings include:

1. On 3/8/23 at 2:32 PM Witness 6 (Family Member) stated he complained for days about the dining room being too cold. Witness 6 stated one of the two heating vents in the dining room did not work and Resident 10 was not comfortable eating in the dining room.

On 3/8/23 at 2:44 PM Staff 35 (Maintenance Director) was asked to measure environmental temperatures in the facility. Staff 35 stated he was aware the living room was cold due to the facility replacing the baseboard heater with two new wall heaters but the room needed more heaters. Staff 35 also stated he learned of the cold temperature in the dining room that day and was working on a repair.

The following environmental temperatures were obtained:
- Outside of room 112: 66 degrees
- Outside the staff office in the 100 hall: 69 degrees
- 200 hallway: 68.2 degrees
- Entrance to the dining room: 66 degrees
- Dining room, far side of the room: 63.3 degrees
- Living room 62.6 degrees

On 3/8/23 at 4:16 PM Staff 1 (Administrator) reviewed the temperatures and stated Staff 35 was working on the repair to the dining room heating. Staff 1 stated she was aware the living room was cold prior to that day and confirmed the facility continued to provide Bingo and exercise activities with residents in the living room.

On 3/8/23 at 4:47 PM Resident 30 was observed in the front hallway, the hallway felt cold and cold air came from an air vent. Resident 30 was wrapped in a blanket.

On 3/8/23 at 4:52 PM Staff 29 (CNA) stated Resident 30 tended to be cold when in the hallway and had a blanket to keep her/him warm.

On 3/8/23 at 4:55 PM Resident 10 was in the dining room for dinner and wore a sweatshirt and stocking cap.

On 3/8/23 at 4:56 PM Resident 37 and Resident 6 sat at a table in the dining room. Resident 37 wore pants and a hooded sweatshirt with a stocking cap, and Resident 6 wore pants and a sweatshirt. Both residents stated the room was cold. Resident 6 stated the room was cold for a few days. Resident 37 stated she/he did not think the room would ever get warm.

On 3/9/23 at 11:26 AM Staff 27 (CNA) stated it was cold in the hallways and common areas and she often wore a jacket when working to stay warm.

, 2. Resident 12 admitted to the facility in 2021 with diagnoses including depression.

A 2/15/23 grievance revealed Resident 12 complained the living room (TV room) was too cold since the new heaters were installed.

On 3/8/23 at 9:59 AM Resident 12 was observed participating in the exercise class in the living room. She/he wore a coat and gloves. The living room felt cold.

On 3/8/23 at 1:50 PM Resident 12 stated the living room was cold and was so for a while.

On 3/8/23 at 2:44 PM Staff 35 (Maintenance Director) was asked to measure environmental temperatures throughout the facility resulting in the following:
- Outside of room 112: 66 degrees
- Outside the staff office in the 100 hall: 69 degrees
- 200 hallway: 68.2 degrees
- Entrance to the dining room: 66 degrees
- Dining room, far side of the room: 63.3 degrees
- Living room 62.6 degrees

Staff 35 stated he was aware the living room was cold. Staff 35 stated the living room had a baseboard heater that was replaced with two wall heaters and he planned on putting more wall heaters on the other side of the room.

On 3/8/23 at 12:51 PM Staff 1 (Administrator) acknowledged she was aware the living room was cold since the new heaters were installed in 2/2023.

On 3/9/23 at 11:26 AM Staff 27 (CNA) stated it was cold in the hallways and common areas and she often wore a jacket when working to stay warm.

Based on interview and record review it was determined the facility failed to investigate an injury of unknown origin for 1 of 2 sampled residents (#47) reviewed for abuse. This placed residents at risk for abuse. Findings include:

Resident 47 was admitted to the facility in 2022 with diagnoses including chronic obstructive pulmonary disease (a lung disease which caused obstructed airflow).

In a public complaint on 1/6/23 Witness 7 (Complainant) stated Resident 47 was admitted to the hospital and observed to have multiple bruises on her/his lower abdomen and groin area.

A 12/13/22 Admission Nursing Database revealed no documentation of bruising on Resident 47's lower abdomen and groin area.

A 12/15/22 Progress Note revealed Resident 47 was found on the floor and obtained a small injury to her/his left forearm but no other injury.

A 12/20/22 Progress Note revealed Resident 47 fell with no injuries.

A 12/22/22 Weekly Skin Audit revealed Resident 47 had no new skin areas and did not identify bruising to the lower abdomen or groin area.

A 1/2/23 Weekly Skin Audit revealed Resident 47 continued to have bruises to both of her/his upper extremities and to her/his right lower body, above the groin, and discoloration to the right lower extremity. The medical record revealed no other documentation of bruising in the abdominal or groin area.

On 3/7/23 at 3:25 PM Staff 33 (LPN) stated she completed the 1/2/23 Weekly Skin Audit and Resident 47 had bruising, she believed it was from a fall Resident 47 had at the hospital, but there was no other documentation related to it and the only documentation she could find about the bruises was in the 1/2/23 Weekly Skin Audit.

On 3/9/23 at 4:08 PM Staff 2 (DNS) stated she reviewed the medical record and believed Resident 47 fell against the bed or had bruising from shots obtained at the hospital. Staff 2 stated there should have been an investigation into the injury of unknown origin to rule out abuse.

Based on observation, interview and record review it was determined the facility failed to assess and complete a significant change assessment for 1 of 1 sampled resident (#13) reviewed for dialysis. This placed residents at risk for unmet needs. Findings include:

Resident 13 was admitted to the facility in 2022 with diagnoses including end stage renal disease.

An Admission assessment dated 11/4/22 documented a BIMS score of 15 (indicating cognitively intact), a depression score of one (no depression), she/he had no behaviors and occasional pain of one (scale of zero-10 with zero meaning no pain and 10 indicating the worst pain imaginable).

A Quarterly assessment dated 2/4/23 documented a BIMS score of nine (moderately impaired), a depression score of six (mild depression), rejection of care one to three days in a seven day period and almost constant pain of nine.

On 3/8/23 at 4:07 PM Staff 5 (RNCM) stated Resident 13 had a decline in mood when her/his significant other was hospitalized. Staff 5 stated Resident 13 had more rejections of care and appeared to have increased pain.

On 3/9/23 at 11:32 Staff 39 (Regional Nurse Consultant) stated the facility was unable to complete the assessment period for a significant change assessment due to Resident 13 being hospitalized. No additional information was provided.

3. Resident 24 was admitted to the facility in 2/2023 with diagnoses including chronic pain and anxiety disorder.

The 10/4/22 revised Shower Schedule indicated Resident 24 was to receive a shower on Wednesday and Saturday evenings.

The 2/8/23 through 3/8/23 Task: Bathing/Showers document revealed Resident 24 did not receive a shower on 2/11/23, 2/18/23, 3/4/23 and 3/8/23.

The 2/24/23 revised care plan indicated Resident 24 required both one and two staff to assist with bathing but no further shower preferences were found.

On 3/6/23 at 12:18 PM Resident 24's room was observed with a sign on her/his wall that indicated showers were to be provided during the day on Wednesday and Saturday. Resident 24 indicated she/he refused showers because of her/his elevated evening pain and stated Staff 2 (DNS) worked with her/him over a month ago to change the shower schedule.

On 3/7/23 at 11:59 AM Staff 2 (DNS) stated the sign in resident's room was the current standard for showers because the shower schedule was being updated and staff were aware.

On 3/8/23 at 11:02 AM Staff 23 (LPN) stated she and Staff 26 (CNA) were not aware of changes to Resident 24's shower schedule until 3/4/23 when Staff 23 had a conversation with Resident 24 because of her/his shower refusals.

On 3/9/23 at 11:26 AM Staff 27 (CNA) stated she was not aware of specific shower needs for residents outside of the master Shower Schedule sheet and if Resident 24 had specific shower expectations it would be in her/his care plan and no shower expectations were indicated.

On 3/9/23 at 2:11 PM Staff 5 (RNCM) stated she had no knowledge of a process in place to revised the master Shower Schedule sheet and the schedule should be followed. Staff 5 stated she was not aware of issues with Resident 24's showers and her/his shower expectations should be indicated in the care plan.



, Based on observation, interview and record review it was determined the facility failed to revise care plans and conduct quarterly care planning conferences for 3 of 5 sampled residents (#s 19, 23 and 24) reviewed for ADLs, constipation and care planning. This placed residents at risk for unmet needs. Findings include:

1. Resident 19 was admitted to the facility in 2021 with diagnoses including Parkinson's disease (a brain disorder affecting movement).

A 9/20/22 progress note revealed Resident 19 had a care conference.

At the time of the survey no documentation was found in clinical records indicating a care conference was held after 9/20/22.

On 3/7/23 at 2:28 PM Staff 4 (Social Service Director) stated care conferences were completed quarterly based on the MDS schedule. Staff 4 confirmed Resident 9 was scheduled for a care conference in 12/2022 but was unable to find documentation to indicate the care conference was conducted.

2. Resident 23 was admitted to the facility in 2021 with diagnoses including stroke.

An Annual MDS was completed in 8/2022. A review of Resident 23's medical record revealed no documentation a care conference was conducted relative to the assessment.

A Quarterly MDS was completed in 11/2022. A review of Resident 23's medical record revealed no documentation a care conference was conducted relative to the assessment.

On 3/7/23 at 2:28 PM Staff 4 (Social Services Director) stated care conferences were conducted quarterly based on the MDS schedule.

On 3/9/23 at 9:41 AM Staff 4 stated Resident 23 was unable to have a care conference in 11/2022 because her/his spouse was in the hospital for a scheduled surgery on 11/26/22. There was no documentation the required care conference was conducted until 2/8/23.

2. Resident 16 was admitted to the facility in 2019 with diagnoses including dementia and stroke.

A consultant pharmacist review dated 2/6/23 noted physician orders for several labs dated 1/17/23. The review asked to ensure the labs were completed and the results were available in the record for monitoring of medications and medical conditions.

A 3/9/23 review of the medical record revealed no information the ordered labs were obtained.

On 3/9/23 at 11:26 AM Staff 2 (DNS) stated the facility attempted to obtain the ordered labs on 3/8/23. Staff 2 stated she did not know if the labs were obtained or provide information to indicate if staff were successful with the lab draw.

, 3. Resident 24 was admitted to the facility in 10/2022 with diagnoses including chronic pain and anxiety disorder.

The facility's Bowel Care Protocol revealed the evening shift was to generate a report of residents who did not have bowel movements for two consecutive days. If a resident did not have a bowel movement for three consecutive days the evening shift nurse was to offer Milk of Magnesia (medication used as laxative).

The 2/7/23 through 2/19/23 Task: Bowel Documentation indicated Resident 24 had no bowel movements from 2/11/23 through 2/19/23 (eight days).

The 2/2023 TAR revealed Resident 24 was first offered Milk of Magnesia on 2/17/23 and the resident refused. No additional bowel interventions were noted.

A 2/24/23 Hospital Discharge Summary revealed Resident 24 was admitted to the hospital on 2/19/23 with multiple issues including complaints of constipation and abdominal pain.

On 3/8/23 at 2:44 PM Staff 38 (RN) stated the night nurse was to make a list of residents who needed bowel care with the option to offer natural remedies to resolve constipation issues. Staff 38 stated the bowel sheet was to be kept on the medication cart to record what bowel medications were offered or if any bowel medications were refused. Staff 38 stated Staff 5 (RNCM) was to receive completed bowel lists and past bowel lists were kept in a binder.

On 3/9/23 at 9:13 AM Staff 23 (LPN) recalled a conversation with Resident 24 when she/he was constipated and stated she did not know how the bowel protocol for Resident 24 was missed. Staff 23 stated there were no bowel logs in a binder and no oversight to ensure bowel care was monitored or completed for Resident 24.

On 3/9/23 at 2:11 PM Staff 5 stated she was recently made aware of the bowel care process and confirmed there was no evidence the process was followed including the use of bowel care logs to monitor residents' bowel movements and bowel care medications or interventions. Staff 5 acknowledged bowel care should have been offered to Resident 24 after three days.




, Based on observation, interview and record review it as determined the facility failed to follow physician orders and ensure bowel care interventions were followed for 3 of 5 sampled residents (#s 6, 16 and 24) reviewed for medications. This placed residents at risk for unmet needs and bowel complications. Findings include:

1. Resident 6 was admitted to the facility in 2013 with diagnoses including dementia.

A 2/6/23 Note to Attending Physician/Provider signed by Resident 6's physician on 2/8/23 revealed the facility was to complete labs to check the valporic acid level (blood test to check medication levels), CBC (complete blood count) and hepatic panel (liver functioning) in one week on 2/15/23.

A review of the clinical records revealed the ordered labs were not completed.

On 3/8/23 at 1:43 PM Staff 5 (RNCM) reviewed the Note to Attending Physician/Prescriber for labs and stated the ordered labs were not completed.

Based on interview and record review it was determined the facility failed to ensure dialysis services were provided to 1 of 1 sampled resident (#16) reviewed for dialysis. This placed residents at risk for lack of dialysis services. Findings include:

Resident 13 was admitted to the facility in 2022 with diagnoses including end stage renal disease.

a. An alert note dated 10/28/22 indicated Resident 13 had a central venous catheter (a tube inserted into a vein) in the chest and a new left arm fistula (a connection between an artery and a vein) for dialysis treatments.

An Admission Database dated 10/28/22 did not identify the presence of the central venous line or the fistula.

The current care plan for dialysis services identified a dialysis access site in the left arm, restricted blood pressures and lab draws on the left arm, provided information related to monitoring for the fistula for bleeding and to obtain "dry weights" (weights obtained after the resident received dialysis).

The 3/2023 MAR instructed staff to supply a snack and verify if consumed, restrictions for blood pressures and lab draws on the left arm, to check the bruit (sound) and thrill (vibration) each shift, monitoring the fistula dressing for bleeding and remove four hours after dialysis treatments.

The MAR and the care plan did not contain information related to the central venous catheter in Resident 13's chest.

A review of dialysis notes from 11/8/22 through 2/8/23 documented location of dialysis access sites as left upper arm, right upper arm, left chest and right chest.

Current treatment orders included:
-Monitor for breakthrough bleeding of the shunt (fistula), apply pressure to site using sterile gauze.
-Check the fistula for bruit and thrill every shift.
-Ensure the dialysis communication form was sent to and returned from dialysis center.
-Monitor the dialysis fistula for signs and symptoms of infection every shift.
-No blood pressure or lab draws on left arm.
-Remove pressure dressing from fistula 4 hours following dialysis treatment.
-Provide a meal or snack to take to dialysis, check upon return to ensure snack was eaten.

On 3/8/23 at 3:54 PM Staff 23 (LPN) was asked about Resident 13's dialysis access site and monitoring. Staff 23 stated she/he had an access site in the left chest and the site was monitored for swelling, bleeding, bruit and thrill.

On 3/8/23 at 4:07 PM Staff 5 (RNCM) was asked about Resident 13's dialysis access site and monitoring. Staff 5 stated she/he had a left arm fistula and the site was monitored for bleeding, bruit and thrill. Staff 5 added the staff were to remove the pressure dressing after four hours upon the resident's return to the facility.

On 3/9/23 at 11:32 AM Staff 2 (DNS) stated Resident 13 had a chest port and a left arm fistula that was currently not being used. The lack of information related to care for both sites, which site was being used for dialysis, the site the staff should be assessing and treatment restricitons for the left arm missing on the Kardex (CNA care directives) were discussed and Staff 2 agreed the information was important.

b. A physician's order dated 10/29/22 instructed staff to send a meal or snack to dialysis treatments and to check with Resident 13 upon return to ensure the meal or snack was eaten.

On 3/8/23 at 11:13 AM Resident 13 was asked about whether she/he took a meal/snack or medications to dialysis treatments and the resident answered "no".

The current MAR was reviewed on 3/9/23 at 10:00 AM and indicated the order related to the meal/snack was documented as completed on each dialysis day.

On 3/9/23 at 11:09 AM Staff 3 (LPN Resident Care Manager) was asked if Resident 13 took a snack to dialysis and she stated she did not know as she was not at the facility when Resident 13 left for dialysis.

On 3/9/23 at 1:32 PM Staff 2 (DNS) was asked about the order for snacks and stated the order should not be on the MAR. Staff 2 stated the dialysis center had snacks for Resident 13 and the orders needed to be updated. Staff 2 was informed of the current order being signed as provided. Staff 2 provided no additional information.

Based on interview and record review it was determined the facility failed to reassess, implement and revise behavioral healthcare needs for 1 of 1 sampled resident (#12) reviewed for mood/behavior health. This placed residents at risk for unmet psychosocial wellbeing. Findings include:

Resident 12 was admitted to the facility in 2021 with diagnoses including depression.

A review of 3/1/22 through 7/24/22 progress notes revealed Resident 12 had no documented behaviors.

A 5/3/22 Quarterly MDS revealed a BIMS score of 15 (cognitively intact), no acute mental status change, a depression scale of 0 (no depression symptoms) and no behaviors.

A 7/25/22 progress note revealed Resident 12 accused Staff 30 (RA) of hitting her/him.

A 7/26/22 progress note stated Resident 12 was crying and stated Staff 30 did not hit her/him.

A 7/28/22 progress noted revealed an investigation regarding an allegation of abuse was completed and abuse was ruled out.

An 8/1/22 Comprehensive MDS revealed a BIMS score of 15, no acute mental status change, a depression score of 7 (mild depression) and one day Resident 12 thought she/he would be better off dead or thought of hurting her/himself. The 8/9/22 Mood CAA revealed no documented behaviors and Resident 9 had ineffective coping and made negative statements.

An 8/10/22 progress note revealed Resident 12 was crying, she/he stated Staff 30 did not do anything wrong and was concerned Staff 30 was mad at her/him.

An 8/13/22 progress note revealed staff was speaking with Resident 12's roommate and Resident 12 told them to "shut up".

An 8/15/22 progress note Resident 12 was tearful after she/he was informed she/he was not to be alone with Staff 30.

An 8/16/22 progress note revealed Resident 12 was tearful.

An 8/26/23 progress note revealed Staff 30 submitted a letter to the administrator that he received from Resident 12 at his home address. This was the third letter Staff 30 received from Resident 12. Staff 30 was uncomfortable with "sexual" content in the letter.

An 8/27/22 progress note revealed Staff 30 contacted the police related to continuing to receive letters at his home from Resident 12.

A 9/2/22 progress note revealed Resident 12 wanted things to go back to normal with Staff 30.

A 9/8/22 Psychotropic Medication Review revealed Resident 12 experienced tearfulness, sad comments and verbal aggression during the last month.

A 9/8/22 Behavioral Health progress note revealed Resident 12 stated she/he did not have affection or support from family. Recommendations included a supervised meeting with Staff 30 and Resident 12 for closure.

A 9/16/22 progress note revealed Resident 12 requested to leave the facility with Staff 30 to have a conversation. The administrator informed Resident 12 Staff 30 was not comfortable being alone with her/him and did not want contact with Resident 12 outside of work. Resident 12 was agitated, yelled at the administrator and expressed she/he felt the staff were trying to control her/his life.

A 9/20/22 progress note revealed Resident 12 was given a guidance list related to the Staff 30 which stated Resident 12 was not to be alone with Staff 30, was not to have contact with Staff 30 outside the facility and was not to have any physically affectionate contact with Staff 30.

A 9/26/22 progress note revealed Resident 12 felt restricted and was referred for a PASRR II (an in-depth psychosocial evaluation) evaluation.

An 10/6/22 progress note revealed Staff 30 assisted Staff 17 (CNA) with a transfer for Resident 12. During the transfer Resident 12 accused both staff of hitting her/him but followed up with, "I'm joking." The administrator informed Resident 12 Staff 30 was not to assist with her/his care anymore and she/he was upset and tearful.

An 10/11/22 Behavioral Health progress note revealed Resident 12 had a new diagnosis of adjustment disorder with mixed anxiety and depressed mood, was going through grief reaction, but remained unchanged since the last visit. Recommendations were made to call for increased therapy.

An 10/14/22 PASRR II Resident Review Screening for Mental Illness revealed Resident 12 was referred for a Level II evaluation on 9/26/22 due to behaviors which jeopardized Resident 12's current facility placement related to stalking and harassment of an employee.

An 10/14/22 Behavioral Health PASRR II progress note stated there were no reported concerns of behaviors prior to the 7/2022 incident and Resident 12 expressed the monthly counseling appointments were not helpful. Recommendation was made for increased therapist appointments.

A 11/1/22 Quarterly MDS revealed a BIMS score of 15, no acute mental status change, a depression score of 6 (mild depression) and no behaviors.

A review of Resident 12's care plan revealed the following interventions:
- 10/27/22 monitor for behaviors of negative statements, verbal aggression, ingesting her/his hair, inability to rest/sleep, refusing showers and refusing medication until educated on each medication.
- 11/10/22 PASRR II completed and to encourage attendance of counseling.
- 12/2/22 Interventions to monitor for antidepressant medication side effects and effectiveness.
- 2/28/23 care in pairs related to history of making accusatory statements toward staff.
- 8/9/22 assist resident through grief process, give medication per orders, mental health evaluation as indicated and ordered and when resident makes negative statements attempt to find out reasons and resolve if possible.

A 11/7/22 Behavioral Health progress note revealed Resident 12 made some improvement and recommendations were made for weekly therapy.

A 12/6/22 Behavioral Health progress note revealed Resident 12 started pulling out her/his hair and eating it as a stress response.

A 12/12/22 Psychotropic Medication Review revealed Resident 12 was tearful, made sad comments and was verbally aggressive the last month.

A 1/16/23 Behavioral Health progress note revealed Resident 12 had moderate improvement since the previous visit.

A 2/2/23 progress note revealed Resident 12 bought food for Staff 30.

A 2/3/23 progress note revealed Resident 12 stated she/he wanted things to go back to normal with Staff 30.

A 2/16/23 progress note revealed Resident 12 accused Staff 4 (Social Service Director) of throwing away clothes and missing items.

A 2/17/23 Behavioral Health Progress note revealed Resident 12's obsessional thoughts continued to negatively impact function and mental health, Resident 12 did not respond well to cognitive-behavioral interventions, and a recommendation to work with the physician for an adjunct medication.

A 2/28/23 progress note revealed Resident 12 stated she/he was not going to complain about anything because everything she/he said, "got twisted and blown out of proportion".

A 2/28/23 Physician Order revealed new orders for Abilify for OCD (Obsessive Compulsive Disorder) management.

A 3/2/23 Psychotropic Medication Review revealed Resident 12 was tearful, made sad comments and was verbally aggressive the last month.

On 3/6/23 at 1:15 PM Resident 12 stated in 7/2022 she/he accused Staff 30 of hitting her/him even though he did not. Resident 12 stated she/he was in love with Staff 30 and sent him letters to his home. Resident 12 expressed feeling hurt when Staff 30 rejected her/him and accused him of hitting even though he did not. Resident 12 stated she/he did not know why she/he said it, Staff 30 was a very nice man and she/he fell in love with him but there was never a relationship. Staff 30 was not allowed to work with her/him. Resident 12 stated feeling sad about the situation.

On 3/8/23 at 2:10 PM Staff 30 stated there was confusion about what he was allowed to do regarding care with Resident 12 after the incident in 7/2022. He was informed he was not allowed to help with any care for Resident 12 after the resident accused him of hitting her/him in 10/2022.

On 3/8/23 at 4:58 PM Staff 31 (RN MDS) stated the need for a Significant Change MDS was determined by triggers on the scheduled MDSs and was appropriate for long term changes in condition. Staff 31 stated he did not receive PASRR II notes for Resident 12, she/he was not reviewed for a significant change and a Significant Change MDS was not completed for Resident 12.

On 3/9/22 at 2:10 PM Staff 17 stated Resident 12 often focused on the negatives of life. Staff 17 stated Resident 12 remained focused on Staff 30 and was more emotional after counseling appointments. Staff 17 said she made a point to keep interactions with Resident 12 positive as much as possible.

On 3/9/23 at 9:41 AM Staff 4 (Social Service Director) stated Resident 12 was fixated on Staff 30 and was unable to move on. Staff 4 stated Resident 12 had a new diagnosis of OCD, had increased emotional behaviors after counseling, her/his depression symptoms waned and she had new behaviors such as suspicion, isolation, making false accusations and eating her/his hair. Staff 4 stated she had not received Resident 12's counseling progress notes and acknowledged she had not followed up on recommendations from the PASRR II or from counselor regarding weekly counseling.

On 3/9/23 10:47 AM Staff 2 (DNS) confirmed Resident 12's counseling notes were not received or reviewed until 3/2/23. Staff 2 stated she was unaware of the weekly counseling recommendation from the PASRR II and monthly counseling progress notes which resulted in a delay of mental health treatment for Resident 12. Staff 2 acknowledged Resident 12 had new behaviors which were not exhibited prior to the event on 7/25/22 and Resident 12 had a significant change with mental health which required a Significant Change MDS with care plan revisions.

Based on interview and record review it was determined the facility failed to monitor psychotropic medication for 1 of 5 sampled residents (#24) reviewed for medications. This place residents at risk for unnecessary medications. Findings include:

Resident 24 was admitted to the facility with diagnoses including chronic pain and anxiety disorder.

The facility's 8/25/20 Psychoactive Medication Management Guideline indicated residents who received psychotropic medications would have a supporting diagnosis, targeted behavior for use and be monitored for effectiveness of the medication therapy.

A 1/17/23 Psychoactive Medication Review progress note revealed Resident 24 was stable on current medications and the care plan was updated.

A 2/9/23 signed physician order indicated as of 10/28/22 Resident 24 received trazodone (antidepressant medication) by mouth at bedtime for insomnia.

Resident 24's clinical record revealed no sleep monitor or care plan related to the resident's sleep.

On 3/8/23 at 11:35 AM Staff 10 (CNA) stated Resident 24 was not monitored for sleep and there was no indication of sleep issues in her/his care plan.

On 3/9/23 at 2:11 PM Staff 5 (RNCM) confirmed Resident 24 was on trazodone for insomnia and acknowledged her/his sleep was not monitored and the care plan was not updated.

Based on observation, interview and record review it was determined the facility failed to promptly provide emergency dental services and interventions to meet residents' needs for 1 of 2 sampled residents (#9) reviewed for dental. This placed residents at risk for unmet dental needs. Findings include:

Resident 9 admitted to the facility in 2021 with diagnoses including diabetes.

A 6/2/22 Annual MDS Dental CAA revealed Resident 9 wore full lower dentures.

A 7/5/22 Grievance Form revealed Resident 9's dentures were missing. A dental appointment was made for 10/20/22, the soonest date available.

An 8/17/22 Physician Order revealed Resident 9's diet texture was changed to soft and bite size due to dental repair.

A 9/2/23 Grievance Form revealed Resident 9's spouse wanted information regarding missing dentures and was notified the dental appointment was on 10/13/22.

A 9/8/22 progress note revealed Resident 9 had a dental appointment on 10/19/22 that was changed to 10/13/22.

An undated Referral Form indicated Resident 9 had insurance approved for upper and lower dentures on 11/2/22.

A 2/3/23 Grievance Form revealed concerns were reported Resident 9 still did not have dentures and had difficulty chewing. A request was made for a SLP evaluation to assess and determine if Resident 9 needed a different diet texture. A 2/6/23 response stated Resident 9 had an appointment on 10/13/22 and after receiving insurance approval an appointment with a denturist was made for 3/13/23, the soonest date available, and Resident 9 was on a mechanical soft diet. No documented evidence was found regarding the requested SLP evaluation.

A 3/10/23 Patient Progress Note from the dentist revealed Resident 9 had no teeth and needed upper and lower dentures.

A review of Resident 9's Care Plan printed on 3/7/23 revealed no interventions related to missing dentures.

On 3/6/23 at 3:45 PM Resident 9 stated her/his dentures were lost a year ago and the facility had not replaced them yet. Resident 9 stated she/he had an appointment on 3/13/23 with a denturist but was frustrated that it took this long. Resident 9 stated she/he was only able to eat food that did not need to be chewed. Resident 9 was observed to have no natural teeth or dentures.

On 3/9/23 at 9:41 AM Staff 4 (Social Services Director) stated she was responsible for making dental appointments. Staff 4 stated when Resident 9's dentures went missing in 7/2022, a dental appointment was made for 10/20/22, changed to 10/13/22, which was the soonest available appointment. Staff 4 acknowledged the lack of documentation related to this appointment until 9/2/22 and the lack of documentation of the facility's effort to obtain timely emergency dental care for Resident 9.

On 3/9/23 at 10:47 AM Staff 2 (DNS) acknowledged the lack of documentation to support the facility's efforts to obtain timely emergency dental care, and lack of documentation to support interventions initiated for Resident 9 to prevent complications related to the prolonged time Resident 9 was without dentures.

Based on observation, interview and record review it was determined the facility failed to ensure meals were provided to meet the needs of residents for 3 of 4 sampled residents (#s 13, 20 and 22) reviewed for food and kitchen. This place residents at risk for lack of adequate nutrition and allergic reactions. Finding include:

1. Resident 13 was admitted to the facility in 10/2022 with diagnoses including heart failure and kidney disease.

The 3/2023 TAR indicated Resident 13 was allergic to grapes and raisins.

Immunization records revealed Resident 13 obtained a skin rash if she/he consumed grapes or raisins.

On 3/9/23 at 9:39 AM Witness 8 (Family Member) stated Resident 13 was provided oatmeal raisin cookies on her/his meal tray earlier in the week and the cookies appeared to be made with chocolate chips until they opened the wrapped cookies together and realized the cookies contained raisins. Wrapped cookies with raisins were observed in Resident 13's room.

On 3/9/23 at 10:46 AM Staff 6 (Dietary Manager) was shown the cookies with raisins from Resident 13's room and acknowledged Resident 13 had an allergy to raisins and should not have received the cookies.

2. Resident 20 was admitted to the facility in 12/2020 with diagnoses including stroke.

The 2/12/23 Nutrition Assessment indicated Resident 20 required increased calories and protein to promote weight gain.

Resident 20's current diet slip indicated she/he was to have large protein portions and fortified cereal and starches at each meal.

On 3/9/23 from 11:50 AM to 12:10 PM during meal service Staff 24 (Assistant Dietary Manager) was observed to read Resident 20's meal ticket, placed diced meat on the resident's plate and covered the plate with a lid for transport. Staff 24 was made aware of Resident 20's diet slip and confirmed the protein portion of meat was not large as the diet slip indicated.

On 3/9/23 at 12:13 PM Staff 6 (Dietary Manager) acknowledged Resident 20's diet slip should be followed.

3. Resident 22 was admitted to the facility in 3/2021 with diagnoses including heart disease and diabetes.

The 1/22/23 Nutrition Assessment indicated Resident 20 was lactose (dairy) intolerant and to avoid dairy products.

Resident 22's current diet slip indicated she/he was to have no dairy products.

On 3/9/23 from 11:50 AM to 12:10 PM during meal service Staff 24 (Assistant Dietary Manager) was observed to read Resident 22's meal ticket, placed chicken with a slice of cheese on the resident's plate and covered the plate with a lid for transport. Staff 24 was made aware of Resident 22's diet slip and confirmed Resident 22 was to receive chicken without cheese.

On 3/9/23 at 12:13 PM Staff 6 (Dietary Manager) acknowledged Resident 22's diet slip should be followed.

Based on observation and interview it was determined the facility failed to ensure equipment was properly sanitized for 1 of 1 kitchen reviewed. This placed resident at risk for food borne illnesses.

During random observations on 3/6/23 and 3/10/23 in the common dining room, plastic pitchers were observed in use by CNAs who assisted residents by pouring their beverages of choice during meal service.

On 3/6/23 from 10:15 AM to 11:30 AM the three compartment sink was observed not in use.

On 3/9/23 at 10:30 AM Staff 23 (Dietary Aide) stated the three compartment sink was only used when the dishwasher was not working. Staff 23 was observed to touch a plastic pitcher held in an unused three compartment sanitation sink and stated the plastic pitchers could not be placed in the dish machine because the dish washer damaged the pitchers. Staff 23 stated the pitchers were cleaned "just like at home" with soapy water.

On 3/9/23 at 12:13 PM Staff 6 (Dietary Manager) observed three plastic pitchers on the clean dish shelf and confirmed the three compartment sink was not used to sanitize the pitchers. Staff 6 stated the three sink method or the dishwasher were the only options allowed to sanitize equipment and it was not done.

Based on interview and record review it was determined the facility failed to accurately track and document the COVID-19 status of 1 of 8 sampled facility staff (#37) reviewed for vaccinations. This placed residents at risk for infection. Findings include:

A COVID-19 Staff Vaccination Status for Providers spreadsheet provided 3/6/23 revealed Staff 37 (RN) had a non-medical exemption for the COVID-19 vaccination.

On 3/8/23 at 10:08 AM Staff 37 stated she thought COVID-19 vaccines were optional for staff at the facility, but she was vaccinated. Staff 37 stated she signed a vaccination declination form because she had two COVID-19 vaccinations and the facility had not asked her for proof of her COVID-19 vaccination.

On 3/8/23 at 2:16 PM Staff 22 (Human Resources) stated he tracked the staff COVID-19 vaccinations. Staff 22 stated when new staff were not interested in the COVID-19 vaccination he let the DNS or infection preventionist know. Staff 22 also stated the facility was "pretty lenient" about non-medical exemptions and new staff did not need to explain why they needed a non-medical or religious COVID-19 exemption. Staff 22 stated Staff 37 gave no explanation as to why she needed a religious exemption for the COVID-19 vaccination but filled out the religious exemption form and was now working. Staff 22 provided Staff 37's 2/26/23 COVID-19 Vaccine Religious Exemption Request Form for a religious exemption with the reason for the exemption written in as "private."

On 3/8/23 at 2:25 PM Staff 36 (Infection Preventionist) stated Staff 37 was vaccinated against COVID-19 and provided a Declination of COVID-19 Vaccination form signed by Staff 37 on 2/27/23 which indicated she had received two vaccines prior to hire.

On 3/8/23 at 3:57 PM Staff 2 (DNS) stated new employees were to provide their COVID-19 vaccination card or proof of vaccination prior to working in the building. Staff 2 stated when new staff requested a non-medical COVID-19 exemption the form was reviewed with human resources and it was required to have an explanation why the non-medical exemption was needed. Staff 2 was unaware Staff 37 had a non-medical exemption for COVID-19 as well as a form which indicated she received two vaccines prior to being hired. Staff 2 confirmed Staff 37 was working in the facility and the documentation regarding her COVID-19 vaccination status was not accurate.

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OAR 411-086-0360 Resident Furnishings, Equipment

Refer to F558
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OAR 411-087-0100 Physical Environment Generally

Refer to F584
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OAR 411-085-0360 Abuse

Refer to F610
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OAR 411-86-060 Comprehensive Assessment and Care Plan

Refer to F637 and F657
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684 and F698
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OAR 411-086-0240 Social Services

Refer to F740
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care

Refer to F758
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OAR 411-086-0210 Dental Services

Refer to F791
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OAR 411-086-0250 Dietary Services

Refer to F803 and F812
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OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F888
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Based on observation, interview and record review it was determined the facility failed to develop and implement comprehensive care plans for 2 of 2 sampled residents (#s 34 and 35 ) reviewed for respiratory care and hearing aides. This placed residents at risk for unmet hearing and respiratory needs. Findings include:

1. Resident 35 was admitted to the facility in 2021 with diagnoses including hearing loss.

The current care plan did not contain information regarding Resident 35's hearing aide.

A physician order dated 12/22/21 indicated Resident 35 had a left ear hearing aid which was to be put in her/his ear by the LN in the morning and then returned to the container in the treatment cart at bed time

Random observations from 1/19/22 through 1/25/22 on day and evening shifts revealed Resident 35 did not have her/his hearing aide in her/his left ear.

On 1/25/22 at 4:11 PM Staff 2 (DNS) confirmed the comprehensive care plan was not developed for Resident 35 in regard to her/his hearing aide.
,
2. Resident 34 was admitted to the facility in 12/2021 with diagnoses including respiratory failure and COPD (chronic obstructive pulmonary disease).

On 1/19/22 at 3:29 PM Witness 1 (family) indicated Resident 34's BiPAP (non-invasive ventilation therapy used to facilitate breathing) machine was not being cleaned, the water reservoir was not being kept filled and the distilled water was left uncapped. Witness 1 said she did not think the nebulizer (machine which changed medical solution to a fine mist which was then inhaled) equipment was getting cleaned either. Witness 1 stated the staff were not cleaning the equipment as required and not watching the water levels which could cause a respiratory infection for the resident.

A 12/20/21 physician order read: "BiPAP-settings per home, every shift for COPD". The order did not include instructions for the care and management of the BiPAP machine.

Additional physician orders dated 12/23/21 contained orders for two Albuterol Solutions (medications which help control the symptoms of lung diseases). Both medications were used with a nebulizer machine. No instructions were found for the care and management of the nebulizer machine.

On 1/26/22 at 4:13 PM Staff 18 (CNA) indicated the resident took care of the BiPAP herself/himself. She handed the machine to the resident who put it on and then Staff 18 turned it on. Staff 18 said she thought the night shift cleaned the respiratory machines but did not know how often. Staff 18 said the day shift generally took the BiPAP equipment off the resident when they arrived in the morning, but they did not clean it. Staff 18 stated she never saw the resident use the nebulizer machine.

A review of Resident 34's care plan revealed it contained no information related to the use and care of the nebulizer. The care plan contained the following minimal information related to the BiPap machine: offer to put on her/his BiPap and resident to wear BiPap when napping and sleeping. There was no information related to care and use of the BiPap machine itself or instructions for staff to manage the use of the machine.

On 1/19/22 at 3:29 PM Staff 2 (DNS) and Staff 3 (RNCM) acknowledged there was not a system in place to ensure the BiPap and nebulizer information related to the use and care of the machines was added to resident's medical record.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing program of activities to meet the activity needs of 1 of 1 sampled resident (#35) reviewed for activities. This placed residents at risk for unmet needs. Findings include:

Resident 35 was admitted to the facility in 2021 with diagnoses including dementia.

During random observations from 1/19/22 through 1/25/22 on day and evening shifts Resident 35 was not observed participating in any activities.

Resident 35's 12/21/21 Activities care plan indicated staff were to invite Resident 35 to activities of interest, provide in-room activity calendar and provide in-room sensory stimulation or tactile materials.

The 12/25/21 Admission MDS indicated Resident 35 liked to read, spend time outdoors, listen to music and spend time away from the nursing home.

A 1/12/22 Activity Progress Note indicated Resident 35 refused tea time. There were no other activity notes in Resident 35's medical record.

On 1/26/22 at 2:28 PM Staff 1 (Administrator) stated Resident 35 did not have activities which would help with mental or physical stimulation and did not receive any activities based on her/his activity choices.

Based on observation, interview and record review it was determined the facility failed to ensure hearing aides were in place for 1 of 1 sampled resident (#35) reviewed for vision and hearing. This placed residents at risk for a decline in hearing and impaired communication. Findings include:

Resident 35 was admitted to the facility in 2021 with diagnoses including hearing loss and dementia.

Resident 35 had one hearing aide for her/his left ear.

Random observations from 1/19/22 through 1/25/22 on day and evening shifts revealed Resident 35 was without her/his hearing aide.

Resident 35's TAR dated 1/1/22 through 1/31/22 indicated the resident had a left ear hearing aide which was to be placed in the resident's ear by the nurse in the morning and was to be returned to the treatment at bedtime by the nurse on duty.

On 1/26/22 at 2:45 PM Staff 1 (Administrator) stated she was aware Resident 35 was very hard of hearing and assumed staff placed the hearing aide daily in the resident's ear to enable communication with her/him. Staff 1 stated she expected staff to follow up to ensure Resident 35 had her/his hearing aide in place daily.

Based on observation, interview and record review it was determined the facility failed to provide nutritional services for 1 of 1 sampled resident (#35) reviewed for nutrition. This placed residents at risk for weight loss. Findings include:

Resident 35 was admitted in 2021 with diagnoses of dementia and dysphagia (difficulty swallowing).

The 12/22/21 care plan indicated Resident 35 required set up assistance to eat. Staff were to instruct the resident to eat in an upright position, eat slowly, chew each bite thoroughly and notify the nurse if Resident 35 had difficulty swallowing or was holding food in her/his mouth. Staff were to provide cueing, encouragement and assistance with eating and drinking as needed.

The 12/22/21 Nutrition and Lifestyle Screen indicated Resident 35 needed to be supervised related to difficulty with swallowing.

A 1/3/22 Dietary Assessment indicated:
Resident 35 required physical assistance with dining. Resident 35 would benefit from nutritional supplementation to help meet nutritional needs. The goal was to establish a stable weight (or gradual gain) over the next quarter.

Resident 35 was observed alone dining in her/his room for meals on 1/19/22 at 12:45 PM, 1/20/22 at 9:28 AM, 1/21/22 at 12:30 PM, 1/25/22 at 1:40 PM and 1/26/22 at 8:51 AM. The following was observed:
- The resident was up in her/his wheelchair during four of four meals observed and one meal the resident was in bed. There was no staff in the room to offer assistance, cueing or supervision.
- Resident 35 was observed in her/his room to take small bites of food then stir the food around the plate. No assistance or supervision was offered by staff.
- On 1/21/22 at 12:30 PM Resident 35 waited for 16 minutes before the first cueing for eating began. Staff 4 (CNA) came to the door and told the resident "take a bite" No further intervention was provided.
- The resident was observed to have difficulty staying awake during 2 of 4 meals. No change in the staff approach to the resident was observed.
- On 1/26/22 at 8:51 AM Staff 11 assisted Resident 35 with eating. Resident 35 responded positively to the active assistance.

On 1/26/22 at 10:08 AM Staff 11 (CNA) stated the resident, who was prone to choking, was accepting of assistance with meals. When the resident was tired she/he required full physical assistance by staff to eat. Staff 11 stated Resident 35 did not always receive the assistance to eat timely. Staff 11 stated the resident always ate better when the staff were there to assist with the entire meal.

On 1/26/22 at 11:02 AM Staff 17 (Speech Therapist) stated Resident 35 needed supervision, cueing and to sit upright for meals. Staff 17 stated the staff needed more education on supervision and cueing for a resident during meals. Staff 17 stated Resident 35 was at risk for aspiration and weight loss.

On 1/26/22 at 11:29 AM Staff 2 (DNS) stated staff were expected to follow the care plan and provide cueing, encouragement and assistance with eating and drinking as needed. Staff 2 acknowledged Resident 35 required one on one assistance with meals.

Based on interview and record review it was determined the facility failed to provide care and services related to the use of BiPap (non-invasive ventilation therapy used to facilitate breathing) and nebulizer (changed medication solution to a fine mist which was inhaled) machines for 1 of 2 residents (#34) reviewed for respiratory care. This placed residents at risk for respiratory infection. Findings include:

Resident 34 was admitted to the facility in 12/2021 with diagnoses including respiratory failure and COPD (chronic obstructive pulmonary disease).

On 1/19/22 at 3:29 PM Witness 1 (family) indicated Resident 34's BiPap machine was not being cleaned, the water reservoir was not being kept filled and the distilled water bottle was left uncapped. Witness 1 indicated the hoses and mask of the BiPap machine were not being cleaned, were soiled and she had to take them home and wash them for the resident. Witness 1 stated the staff were not cleaning the equipment as required and not monitoring the water levels which put the resident at risk for a respiratory infection.

A 12/20/21 physician order read: "BiPAP-settings per home, every shift for COPD". The order did not include what the home settings were or instructions for the care and management of the BiPap machine.

Resident 34's physician orders dated 12/23/21 contained orders for Ipratropium-Albuterol Solution and Albuterol Sulfate (medications which help control the symptoms of lung diseases). Both medications were used with a nebulizer. No instructions were found for the care and management of the nebulizer machine.

A review of the residents 12/2021 and 1/2022 MAR and TAR revealed no information related to the care and management of Resident 34's respiratory equipment including the BiPap and nebulizer machines.

On 1/19/22 at 3:29 PM Staff 2 (DNS) and Staff 3 (RNCM) acknowledged there was not a system in place to ensure the BiPap and nebulizer information related to the use and care of the machines was added to residents' MARs or TARs. Additionally, the BiPap machine should have settings noted but there were none and none were documented in Resident 34's medical record. The nebulizer machine instructions were not on the TAR and were not in the physician orders. Staff 3 indicated it was their mistake that it was not entered correctly into the resident's medical record.

Based on observation, interview and record review it as determined the facility failed to have orders and care planned interventions for dialysis care in place for 1 of 1 sampled resident (#33) reviewed for dialysis. This placed residents at risk for unmet dialysis care needs. Findings include:

Resident 33 was admitted to the facility in late 2021 with diagnoses including end stage renal disease (ESRD) requiring dialysis (a process to remove toxins from the blood).

On 1/19/22 at 3:30 PM Resident 33's dialysis access site was observed to be in her/his right chest with a clear dressing on the insertion site and the end of the central line (CVC) was wrapped with gauze and taped to protect the end caps.

On 1/25/22 at 12:25 PM Resident 33 stated the dates and times of her/his dialysis. Resident 33 added she/he took a blood pressure medication to dialysis but did not take food to appointments and ate prior to leaving the facility. Resident 33 denied problems with her/his dialysis access site.

Current orders for Resident 33 included:
-Resident must go to dialysis on a hoyer (mechanical lift) sling and "must" bring a meal or snack.
-Check dialysis shunt (a synthetic tube used to connect an artery and vein for dialysis access) for bruit (swishing sound) and thrill (vibration) every shift.
-Shunt in right "arm/thigh", no blood pressure or lab in right "arm/thigh".
-Monitor dialysis shunt for signs of infection, redness, warmth or swelling and report any signs to MD every shift.

The current care plan for Resident 33 included:
-Encourage to consume optimal oral intakes with interventions including renal diet, high protein foods, labs, offer large protein portions with meals, dietician to evaluate as needed, daily renal vitamin.
-Diagnosis of renal failure with interventions of call unit for any questions, no blood draws or blood pressure in arm with graft, encourage resident to go on scheduled days, monitor port on right chest for bleeding or signs of infection every shift.
-Resident is non-compliant with dialysis diet.

On 1/26/22 at 10:14 PM Staff 7 (LPN) stated Resident 33 received dialysis through her/his right chest and a medication was sent with the resident to manage low blood pressure during dialysis. Staff 7 added when Resident 33 returned staff took vitals, noted the dry weight and assessed her/his port. Staff 7 described the central line was wrapped and taped to prevent access for any reason other than dialysis.

On 1/27/22 at 9:50 AM Staff 13 (RN) stated Resident 33 went to dialysis three days per week and took a medication to dialysis. Staff 13 further added she checked her/his lungs, took vitals, documented dry weights, checked the dialysis site and assessed for redness or bleeding but she did not check for bruit or thrill because Resident 33 had a central line.

On 11/27/22 at 10:57 PM the incorrect location and care of Resident 33's dialysis access site was discussed with Staff 2 (DNS). Staff 2 stated the information was entered at the time of admission and the nurses should have deleted the orders that did not pertain to Resident 33.

Based on interview and record review it was determined the facility failed to monitor the effectiveness of cholesterol medications for 2 of 5 sampled residents (#s 4 and 17) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include:

1. Resident 4 was admitted to the facility in 2019 with diagnoses including stroke and dementia.

Physician orders at the time of admission included Atorvastatin (a cholesterol lowering medication).

The medical record noted results of a lipid panel (lab to evaluate cholesterol levels) completed in 6/2020.

Lab monitoring of Atorvastatin was recommended to be completed annually.

No other lab monitoring could be located for Atorvastatin.

On 1/27/22 at 11:45 AM Staff 2 (DNS) stated she could not locate a more recent lab evaluation for the use of Atorvastatin.


2. Resident 17 was admitted to the facility in 2020 with diagnoses including heart disease.

Physician orders dated 9/3/20 included Rosuvastatin (a cholesterol lowering medication).

The medical record noted results of a lipid panel (lab to evaluate cholesterol levels) completed in 12/2020.

Lab monitoring of Rosuvastatin was recommended to be completed annually.

No other lab monitoring could be located for Rosuvastatin.

On 1/27/22 at 11:45 AM Staff 2 (DNS) provided a copy of a lab dated 12/20/20 and stated she could not find any additional labs for the evaluation of Rosuvastatin.

Based on observation and interview it was determined the facility failed to secure 1 of 2 treatment carts during random observations. This placed residents at risk for unauthorized access to medications and treatments. Findings include:

On 1/19/22 at 1:19 PM a treatment cart which contained insulin and syringes was observed to be unlocked and unattended on the 200 hall.

On 1/19/22 at 1:22 PM Staff 8 (CMA) acknowledged the treatment cart was unlocked and unattended.

On 1/20/22 at 10:25 AM a treatment cart which contained insulin and syringes was observed to be unlocked and unattended on the 200 hall.

On 1/20/22 at 10:29 AM Staff 7 (LPN) acknowledged the treatment cart was unlocked and unattended.

On 1/20/22 at 10:32 AM Staff 2 (DNS) acknowledged all treatment carts should be locked when unattended.

Based on interview and record review it was determined the facility failed to ensure reference checks were completed for newly hired facility staff. This placed residents at risk for abuse. Findings include:

On 1/25/22 at 4:35 PM a Facility Personnel Review document for background history checks, references and licenses for newly hired facility staff was given to Staff 19 (Business Office Manager) to complete. The form was used to determine if newly hired staff had completed the necessary steps, including reference checks, required for employment. Staff 19 returned the forms and the reference check section was marked as no reference checks had been completed.

On 1/26/22 at 8:31 AM Staff 14 (Human Resource) stated he was not aware he was supposed to complete the reference checks for newly hired staff.

**********************
OAR 411-086-0060 Comprehensive Assessment and Care Plans


Refer to F656
**********************
OAR 411-086-0230 Activity Services


Refer to F679
**********************
OAR 411-086-0110 Nursing Services: Resident Care


Refer to F685, F695 and F698
**********************
OAR 411-086-0140 Nursing Services: Problem Resolution and Preventative Care


Refer to F692 and F757
**********************
OAR 411-086-0260 Pharmaceutical Services


Refer to F761
**********************

Based on interview and record review the facility failed to address grievances for 1 of 5 sampled residents (#1) reviewed for accidents. This placed residents at risk for unresolved grievances. Findings include:

Resident 1 admitted to the facility in 2020 with diagnoses including End Stage Renal Disease.

A 6/7/21 Grievance Communication Form revealed Resident 1 expressed concerns including staff being rough with care and not listening to what she/he said. The grievance was responded to by the facility on 6/11/21 but did not address staff being rough with care and not listening to Resident 1.

In an interview on 7/21/21 at 11:09 AM Resident 1 stated she/he reported Staff 24 (CNA) being rough with care but did not know what happened regarding the report.

In an interview on 7/27/21 at 10:38 AM Staff 2 (DNS) reviewed the 6/7/21 Grievance Communication Form, confirmed there was no follow up on the form related to the staff being rough and not listening to Resident 1, and stated she believed there was an investigation regarding the concern, but could not find one.

Based on interview and record review it was determined the facility failed to follow physician orders for 3 of 5 sampled residents (#s 1, 4 and 19) reviewed for medication administration. This placed residents at risk for unmet needs. Findings include:

1. Resident 4 admitted to the facility in 4/2020 with diagnoses including dementia and anxiety disorder.

On 7/29/20 a public complaint was received which alleged Resident 4 received unnecessary medication that was discontinued at the hospital.

A physician order dated 4/15/20 directed staff to discontinue the following medications:
-Atorvastatin (a cholesterol medication)
-Famotidine (a heartburn medication)
-Quetiapine (an antipsychotic medication)

A review of the 4/2020 MARs revealed the following:
-Atorvastatin was administered on 4/15/20 and 4/16/20. The resident refused the medication on 4/17/20 the medication was discontinued 4/18/20.
-Famotidine was administered two times daily on 4/15/20 and 4/16/20. The resident refused the medication on 4/17/20 and she/he was given a morning dose on 4/18/20 and the medication was discontinued on the evening on 4/18/20.
-Quetiapine was administered two times daily on 4/15/20 and 4/16/20. The resident refused the medication on 4/17/20, she/he was given a morning dose 4/18/20 and the medication was discontinued on the evening of 4/18/20.

A Medication Error report dated 4/18/20 indicated the above medications were discontinued on 4/15/20 and signed by the physician however they were transcribed and entered into the system to be administered.

On 7/21/21 at 8:40 AM Staff 1 (Interim Administrator) and Staff 2 (DNS) stated the medications were transcribed incorrectly and should not have been entered into the system to be administered. Staff 1 and Staff 2 stated staff were expected to double check orders timely and should be reviewed immediately with a new admission.

2. Resident 19 admitted to the facility in 7/2021 with diagnoses including endocarditis (inflammation of the hearts inner lining of the heart) and atrial fibrillation (rapid heart rate causing poor blood flow).

A physician order dated 7/7/21 directed staff to administer Ampicillin (an antibiotic) intravenously (IV) every six hours for an infection.

A review of the 7/2021 TARs revealed Resident 19 did not received her/his Ampicillin on 7/18/21 at 9:00 PM, 7/19/21 at 3:00 AM, 7/20/21 at 9:00 PM and 7/21/21 at 3:00 AM.

On 7/21/21 at 7:08 PM Staff 12 (RN) stated Resident 19 was supposed to receive her/his Ampicillin for her/his endocarditis every six hours however not all staff were following physician orders. Staff 12 indicated she reported concerns to management.

On 7/22/21 at 2:48 PM Staff 13 (RN/RCM) stated she was aware Resident 19 missed some days of her/his Ampicillin and the physician was notified after this was brought to her attention.

On 7/26/21 at 12:19 PM Staff 2 (DNS) stated she expected staff to implement and follow physician orders for Resident 19's Ampicillin. Staff 2 stated additionally the physician should have been notified Resident 19 did not receive her/his IV antibiotics as ordered.
,
3. Resident 1 admitted to the facility in 2020 with diagnoses including End Stage Renal Disease.

A physician order dated 2/28/21 revealed Eliquis (a blood thinner) was to be administered two times daily.

A 3/24/21 progress note indicated Resident 1's Eliquis was to be held prior to a 3/30/21 scheduled procedure.

A review of the 3/2021 MAR revealed Resident 1 received Eliquis on 3/30/21.

A 3/30/21 progress note revealed Resident 1 received a dose of Eliquis and was unable to undergo the scheduled procedure due to the error.

In an interview on 7/22/21 at 5:03 PM Staff 2 (DNS) confirmed Eliquis was given in error on 3/30/21 and Resident 1's procedure was delayed as a result.

Based on interview and record review it was determined the facility failed to ensure staff followed the care plan and ensured a mechanical lift was in safe operating condition for 2 of 5 sampled residents (#s 16 and 22) reviewed for accidents. Resident 16 experienced a fall and sustained bilateral lower leg fractures. Findings include:

1. Resident 16 was admitted to the facility in 11/2020 with diagnoses including stroke, dementia and Parkinson's disease.

A Significant Change MDS dated 11/23/20 indicated Resident 16 was rarely understood and had short-and-long term memory issues. Resident 16 required extensive two person assistance with bed mobility and transfers.

A comprehensive care plan initiated on 5/7/12 indicated Resident 16's cognitive status varied, some days she/he was able to speak in complete sentences, and other days she/he had a blank stare. A revised care plan dated 11/16/18 indicated Resident 16 was at risk for falls due to poor balance, Parkinson's disease, contractures and dementia. Staff were directed when Resident 16 was in her/his recliner to place the remote control for the recliner out of her/his reach (per Resident 16's agreement).

A Fall Incident Report dated 9/12/20 revealed the following:

-Resident 16 was transferred to her/his recliner by two CNAs with a mechanical lift.
-Staff 9 (CNA) stated when she placed Resident 16 in the recliner she placed both the call light and remote to the recliner in her/his lap and left the room, Staff 9 returned shortly after putting Resident 16 in the recliner, found Resident 16 on the floor face down and called for help. Staff 5 (LPN) entered the room and indicated the recliner was reclined all the way back and the remote was wedged under Resident 16's arm. Staff 5 indicated Resident 16 possibly activated the remote, the recliner reclined up and forward and Resident 16 fell out of the recliner onto the floor face down.
-Resident 16 was assessed by Staff 5 and she/he had a golf size bump to her/his right temple, a large bruise to the back of her/his right hand and bruising to her/his right and left lower shin area. The resident was not taken to the hospital.
-On 9/14/20 Resident 16 stated she/he was transferred into the recliner using the mechanical lift, the CNAs left the room and not much longer after the CNAs left the chair started to lift up. Resident 16 stated she/he attempted to yell for help but no one heard her/him yelling. Resident 16 stated the remote was not under her/his arm but thought she/he might have been placed on top of the recliner remote and ultimately fell onto the floor.
-On 9/16/20 it was determined after Resident 16 was transferred into her/his recliner Staff 9 placed the call light and remote control to the chair in Resident 16's lap and the resident possibly pushed the recliner button instead of the call light, which caused the chair to lift up and dump the resident out and onto the floor. The fall resulted in multiple injuries including a bruise to her/his forehead and bilateral lower leg fractures. Abuse was ruled out however neglect was unable to be determine because the care plan was not followed at the time of the fall.

A progress note dated 9/14/20 revealed Resident 16 had a fall over the weekend and had BLE (bilateral lower extremity) swelling and bruising to both her/his shins and the resident was complaining of increased pain rated nine out of 10. The resident was sent to the hospital and at approximately 3:00 PM the hospital reported Resident 16's imaging results showed she/he had BLE lower leg fractures. The resident returned to the facility and had splints with ace wraps to her/his BLE (from upper thigh to ankle). The resident also had a new pain medication for pain control.

On 7/20/21 at 4:21 PM Staff 6 (LPN) stated he remembered the incident on 9/12/20 because " I flipped my noodle" when he heard Resident 16 had fell out of her/his recliner. Staff 6 stated staff were expected to follow the care plan and additionally he was upset that the resident was not sent out to the hospital until one or two days after the fall, and at the hospital Resident 16 was evaluated with BLE leg fractures.

On 7/21/21 at 10:34 AM Staff 5 stated she remembered the 9/12/20 incident because she was called to the room by Staff 9. Staff 5 stated when she walked into the room the resident was on the floor and the recliner was tilted up and forward. Staff 5 indicated she assessed Resident 16 for injuries and she/he had a bump to her/his head and abrasions to her/his shins but was not sent out to the hospital until the next day. Staff 5 further stated while the resident was at the hospital it was discovered she/he had BLE leg fractures.

On 7/21/21 at 2:25 PM Staff 9 stated she remembered the 9/12/20 incident with Resident 16. Staff 9 stated she transferred the resident into her/his recliner with another staff person. Staff 9 stated she could not remember if she placed the remote and call light in the resident's lap but somehow the resident got hold of the recliner remote resulting in her/his fall out of the recliner.

On 7/26/21 at 12:17 PM Staff 2 (DNS) stated she did not work for the facility when the 9/12/20 fall occurred but would have expected staff to follow the care plan, which was to keep the recliner remote out of reach of Resident 16.

2. Resident 22 was admitted to the facility in 11/2020 with diagnoses including osteoarthritis, muscle weakness and obesity.

A Quarterly MDS dated 5/18/21 indicated Resident 22 had a BIMs score of 15 which indicated she/he was cognitively intact.

A comprehensive care plan initiated on 2/16/21 indicated Resident 22 was a two-person mechanical lift for transfers from her/his bed to electric wheelchair.

A Fall incident report dated 5/29/21 revealed the following:

-Staff 16 (LPN) indicated Resident 22 had a witnessed fall from the mechanical lift sling during a transfer when one of the legs strap came undone and the resident fell onto the ground. The resident complained of right shoulder pain and pain to the back of her/his head. The resident had an abrasion to the back of her/his right shoulder approximately four inches long. No injuries were noted to her/his head. Resident 22 was unable to raise her/his right arm above 45 degrees and was sent out to the hospital.
-On 6/2/21 Staff 15 (CNA) and Staff 14 (CNA) stated they were laying the resident back down into her/his bed via mechanical lift. While in the air one of the bottom leg straps of the mechanical lift sling came undone and Resident 22 fell out of the sling onto the ground.
-On 6/3/21 it was determined abuse and neglect were ruled out as the CNAs transferred the resident appropriately. The mechanical lift was removed from use because a safety guard to prevent the lift sling from becoming unhooked was not in place. Staff were educated not to utilize the mechanical lift if the guards were missing. The resident was sent out to the hospital on 5/29/21 and returned the same afternoon with no new diagnoses but had a large bruise to her/his right posterior shoulder.

On 7/22/21 at 3:18 PM Resident 22 stated she/he had a fall during a mechanical lift transfer in 5/2021. Two CNAs were transferring her/him back to bed and the mechanical sling came undone and "I fell to the floor, hit my head, and was pretty shook up." Resident 22 stated she/he was sent out to the hospital and came back the same day. Resident 22 stated she/he had a large purple bruise to her/his right shoulder and staff monitored the bruise. The resident stated the bruise was no longer on her/his right shoulder.

On 7/22/21 at 4:54 PM Staff 14 stated Resident 22 was alert and oriented, and was a two-person transfer with the mechanical lift. Staff 14 stated on 5/29/21 she and Staff 15 transferred the resident from her/his electric wheelchair to the bed. Staff 14 stated they hooked Resident 22 up to the lift via the sling and started to move her/him towards the bed. Then one of the straps by her/his leg came unhooked and the resident slid feet first down onto the floor. Staff 14 stated the resident was scared and crying when she/he initially fell to the ground, and Resident 22 was sent out to the hospital and came back later that afternoon. Staff 14 stated she did not recall seeing anything missing on the lift when they transferred her/him that day. Staff 14 stated the lift was removed from service.

On 7/22/21 at 5:33 PM Staff 15 stated on 5/29/21 Resident 22 needed to be transferred back into bed. Staff 15 stated she and Staff 14 utilized the mechanical lift, hooked the resident up to the lift via the sling and did not see any safety features were missing or out of place. Staff 15 stated once they got Resident 22 in the air and started to move her/him one of the leg straps came unhooked and the resident slipped out of the sling feet first and hit her/his back and then the right shoulder. Staff 15 stated the resident was "in shock" but did not appear painful. Staff 16 assessed the resident and the resident was sent out to the hospital. Staff 15 stated the facility had three mechanical lifts, and two were newer, and the one they used on the resident on 5/29/21 was the oldest (third) but she did not see anything that looked unsafe when they hooked the sling up for the transfer.

On 7/22/21 at 5:52 PM Staff 16 stated she was called into Resident 22's room on 5/29/21 due to a fall. Staff 16 entered the room and the resident was "pretty shaken up" and had significant pain to her/his right shoulder and decreased mobility. Staff 16 stated the resident hit her/his head on the floor and she initiated neurological checks. Staff 16 stated they got Resident 22 back into bed and then sent her/him out to the hospital. The resident returned from the hospital the same afternoon with no new diagnoses.

On 7/26/21 at 10:01 AM Staff 21 (Maintenance Director) stated he recalled the incident with the mechanical lift on 5/29/21 because he removed the lift from the service because it was missing a safety clip. Staff 21 stated the lift that was removed from service, was an older model with safety clips to keep the sling in place. Staff 21 stated he ordered new parts for the lift.

On 7/26/21 at 12:35 PM Staff 2 (DNS) stated they discovered the lift was missing a metal clip which prevented the sling from coming unhooked. Staff 2 stated they were not sure how long the clip was missing.

Based on interview and record review it was determined the facility failed to effectively manage pain for 1 of 3 sampled residents (#1) reviewed for pain. This placed residents at risk for increased pain. Findings include:

Resident 1 admitted to the facility in 2020 with diagnoses including End Stage Renal Disease.

A 4/13/21 Annual MDS revealed Resident 1 had pain frequently, pain limited daily activities, and her/his worst pain was at an eight out of 10 on a pain scale of one to 10.

A 6/9/21 Grievance Communication Form revealed Resident 1 identified a concern about running out of medication, immediate action taken by facility included "Yes, oxycodone (narcotic pain medication) was unavailable x1 day, Norco (narcotic pain medication) was available".

The 6/2021 MAR revealed Resident 1 had an order for Oxycodone to be given as needed every six hours for pain. Oxycodone was administered at least every day in 6/2021 except for 6/9/21. The MAR also revealed Resident 1 had an order for hydrocodone-acetaminophen tablet every 4 hours as needed for oral pain.

A 6/9/21 Progress Note revealed Resident 1 was administered PRN hydrocodone to dialysis rather than the usual oxycodone because it was not available. Due to it not being the usual pain medication the dialysis staff were uncomfortable administrating the hydrocodone and Resident 1 did not have the pain medication available at dialysis.

In an interview on 7/20/21 at 2:29 PM Witness 24 (family member) stated the facility ran out of Resident 1's oxycodone in 6/2021.

In an interview on 7/22/21 at 11:58 AM Staff 5 (LPN) stated the facility had issues with medications running out due to staff not reordering timely. Staff 5 stated Resident 1 went without pain medications, however did not recall what specific day.

In an interview on 7/23/21 at 1:56 PM Staff 23 (CMA) stated the facility had issues running out of pain medications due to reordering problems.

In an interview on 7/23/21 at 3:57 PM Staff 8 (CMA) stated Resident 1 had a lot of pain especially after dialysis. Staff 8 stated the facility ran out of Resident 1's pain medications a couple times due to reordering issues.

In an interview on 7/26/21 at 10:32 AM Staff 13 (RN/RCM) stated the facility ran out of pain medications for Resident 1 in the past.

In an interview on 7/27/21 at 10:38 AM Staff 2 (DNS) confirmed Resident 1 did not receive oxycodone during 6/2021 due to the medication not being reordered timely.

Based on interview and record review it was determined the facility failed to provide adequate nursing staff to maintain the highest practicable well-being for 2 of 3 halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include:

A public complaint was received on 6/8/21 alleging the facility did not have adequate staffing to meet Resident 13's ADL care needs.

On 7/20/21 at 4:21 PM Staff 6 (LPN) stated the facility was often short staffed. Staff 6 stated in 4/2020 through 6/2021 he was often the only LPN working the floor and night shift only had one or two CNAs assisting residents when they should have three CNAs based on census. Staff 6 stated residents sat in wet and soiled briefs greater than 25 minutes due to short staffing CNAs were not able to get to the residents timely. Staff 6 stated he reported this to management.

On 7/21/21 at 10:34 AM Staff 5 (LPN) stated they often were short staffed and did not always have an RN in the building. Staff 5 stated they often ran short on CNAs and were short one or two CNAs on any shift based on census. Staff 5 stated residents sat in wet and soiled briefs from 25 to 30 or more minutes because CNAs could not answer call lights timely. Staff 5 stated some residents had skin breakdown due to sitting in wet and soiled briefs. Staff 5 stated management was aware.

On 7/21/21 at 12:43 PM Staff 11 (CNA) stated they were short staffed a couple days ago. They should have six CNAs and only had five. Staff 11 stated they were short CNAs often and residents sat in wet and soiled briefs because they could not answer call lights timely. Staff 11 stated not all staff helped out with resident care and she had reported concerns to management.

On 7/21/21 at 2:25 PM Staff 9 (CNA) stated the facility often was short staffed on evening and night shift. Staff 9 stated residents often complained to her regarding long call light wait times and sitting in wet and soiled briefs.

On 7/21/21 at 3:16 PM Staff 3 (CNA) stated they were often short staffed on night shift with only one or two CNAs scheduled when they were supposed to have three. Staff 3 stated they were short staffed on 7/18/21 on night shift. Staff 3 stated residents complained of long call light wait times and sitting in wet and soiled briefs, and stated many residents in the building required two person assist with ADL care. It could take up to 30 minutes to provide incontinence care and was difficult because she could not get to her residents as quickly as she wanted.

On 7/21/21 at 8:18 PM Staff 4 (LPN) stated typically she was the only nurse on day shift because RNs and management did not assist and this happened "all the time" during 4/2020 and 5/2020 but was an ongoing concern. Staff 4 stated CNA shortages were common as well and it was difficult for CNAs to provide appropriate care to residents. Staff 4 stated residents sat in wet and soiled briefs due to long call light wait times because of staff shortages, and residents had skin breakdown as a result. This was reported to management on multiple occasions.

On 7/21/21 8:28 PM Staff 8 (CMA) stated she was responsible for medication administration to all residents in the building and was difficult to administer medications timely to all the residents. Staff 8 stated she was often over the two-hour window (one hour before and one hour after) for timely administration of medications. Staff 4 stated she brought concerns to management on multiple occasions.

On 7/22/21 at 12:31 PM Resident 20 stated she/he resided on the 300 hall and her/his call light was not be answered for 30 to 60 minutes and she/he indicated all shifts were "terrible about answering call lights timely." Resident 20 stated "today" she waited 25 minutes and soiled herself/himself and staff had to change out her/his entire bedding. Resident 20 stated she/he sat in wet briefs on multiple occasions. Resident 20 further stated she/he woke up to her/his bed being soaked in urine and her/his skin was burning, red and irritated. Resident 20 stated staff "don't seem to care."

On 7/22/21 at 1:16 PM Resident 21 stated she/he resided on the 300 hall, required assistance with toileting and she/he wore an incontinent brief. Resident 21 stated call lights took 30 minutes or longer before she/he received help and because of this she/he sat in wet and soiled briefs. Resident 21 stated two or three times in the last month she/he was soaked clear through to her/his bed because no one checked or provided incontinence care, and she/he was "irritated." Resident 21 stated they were short staffed on all shifts and call light response was never timely.

On 7/22/21 at 3:18 PM Resident 22 stated the facility was always short staffed on all shifts and call lights were never answered timely. Resident 22 stated evening and night shifts were the worst, she/he was placed on a bed pan on 7/22/21 and left on the bed pan for 25 minutes, "I was very uncomfortable." Resident 22 stated she/he had been left on the bedpan numerous times on all shifts and for 20 minutes or longer. Resident 22 further stated she/he sat in wet briefs for extended periods of time and reported these concerns to management but "nothing happens."

On 7/22/21 at 4:00 PM Resident Council minutes were requested for the months of 4/2020, 5/2020, 9/2020 and 6/2021 which revealed the following:

4/2020:
-Call light wait times were long. The CNAs came in and turned off the call light and stated "I will be back to assist you onto the toilet" and would not return for 45 minutes.
-Action Taken: The facility was working on new call light system and call light audits were being completed. Continued to communicate with staff they should never leave the resident and state "I'll be right back" when this rarely happened. Will continue to communicate with staff on how to manage care and time management.

5/2020:
-Call light wait times were long and CNAs stated, "you are going to have to wait until the next shift."
-Action Taken: Call light audits were monitored and had been fair to good, needed some work. [No times given as to how long call lights took to answer]. Staff educated on not to tell the residents they would have to wait until the next shift to get ADL care.

9/2020:
-In an interview on 7/22/21 at 4:00 PM Staff 1 (Interim Administrator) and Staff 2 (DNS) were present. Staff 1 stated she could not locate the Resident Council minutes for 9/2020. Staff 1 and Staff 2 stated the call light system to print the call light wait times was not working.

6/2021:
-Residents were concerned with no CNA coverage when CNAs took breaks or lunch and had to wait until the CNA got back from break. Residents indicated wait times were longer than 30 minutes for assistance. CNAs come in and shut off the call lights and said "I'll be back" but did not return for 30 minutes.
-Action Taken: No documentation to indicate this was addressed with management.

On 7/26/2021 at 12:22 PM Staff 1 and Staff 2 stated they worked with multiple agencies to provide appropriate staff coverage in the building and indicated they were working on changing work schedules to accommodate the needs of resident care. When asked how long staff should take to answer call lights Staff 1 and Staff 2 stated they expected call lights to be answered within 15 to 20 minutes.

Based on interview and record review it was determined the facility failed to staff a registered nurse for eight consecutive hours per day seven days per week for 14 out of 78 days reviewed for staffing. This placed residents at risk for unassessed needs. Findings include:

A review of the Direct Care Staff Daily Reports revealed the following:

-4/10/20 through 4/30/20 revealed there were three days without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period.

-9/10/20 through 9/27/20 revealed there were four days without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period.

-6/1/21 through 6/20/21 revealed there were six days without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period.

-7/1/21 through 7/19/21 revealed there was one day without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period.

On 7/26/21 at 12: 22 PM Staff 1 (Interim Administrator) and Staff 2 (DNS) stated they did not work in the building during the months of 4/2020 or 9/2020 and were not sure how they addressed RN coverage. Staff 1 stated they were working to ensure the facility had appropriate RN coverage.

Based on interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 55 out of 78 days reviewed for staffing. This placed residents at risk for lack of accurate staffing information. Findings include:

A review of the Direct Care Staff Daily Reports, for the months of 4/2020, 9/2020, 6/2021 and 7/2021 revealed 55 instances when portions of the form were left blank or were inaccurate. The incomplete or inaccurate information included daily census, number of hours worked by staff and appropriate signature verification for each shift.

On 7/26/21 at 12:22 PM Staff 1 (Interim Administrator) and Staff 2 (DNS) acknowledged the Direct Care Staff Daily Report forms were incomplete and inaccurate for the 55 instances and should have been completed by the staff.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 31 days (77 out of 234 shifts) reviewed for minimum CNA staffing. This placed residents at risk for unmet needs. Findings include:

A review of the facility's Direct Care Staff Daily Report forms and payroll documentation revealed the facility failed to meet the minimum staffing for CNAs 77 out of 234 shifts reviewed.

-4/2020: 22 out of 63 shifts did not have appropriate CNA coverage.
-9/2020: 23 out of 54 shifts did not have appropriate CNA coverage.
-6/2021: 17 out of 60 shifts did not have appropriate CNA coverage.
-7/2021: 15 out of 57 shifts did not have appropriate CNA coverage.

On 7/26/21 at 12:22 PM Staff 1 (Interim Administrator) and Staff 2 (DNS) were present for an interview. Staff 1 stated she was not in the building during 4/2020 and 9/2020 and could not speak to CNA staffing during those months. Staff 1 and Staff 2 acknowledged the lack of CNA coverage for 6/2021 and 7/2021.











Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained on 9 out of 22 days from 9/13/21 through 10/4/21 reviewed for minimum CNA staffing. This placed residents at risk for unmet needs. Findings include:

Due to Oregon's current statewide hospital capacity crisis, the Oregon Department of Human Services, Safety, Oversight and Quality Unit temporarily revised the Oregon Administrative Rules (OARs) related to certified nursing assistant staffing, effective immediately. The Department temporarily amended the minimum certified nursing assistant ratios as follows:
Current OARs for Certified Nursing Assistants (411-086-0100(C)):
o DAY SHIFT: 1 certified nursing assistant per 7 residents.
o EVENING SHIFT: 1 certified nursing assistant per 9.5 residents.
o NIGHT SHIFT: 1 certified nursing assistant per 17 residents.
Effective August 24th, 2021, Temporary OARs for Certified Nursing Assistants (411-086-0100(C)):
o DAY SHIFT: 1 certified nursing assistant per 8.5 residents.
o EVENING SHIFT: 1 certified nursing assistant per 12 residents.
o NIGHT SHIFT: 1 certified nursing assistant per 18 residents.
The Department also temporarily expanded definitions of who can be counted towards the minimum certified nursing assistant ratios. Effective immediately, nursing facilities may temporarily utilize the services of nursing assistants, personal care assistants, physical therapists, and occupational therapists to account for up to 25% of the required minimum staff required on each shift.
The revised staffing ratios and use of staff other than certified nursing assistants to meet the minimum CNA staffing ratio is a temporary measure and will only be allowed during this statewide emergency.

A review of the facility's Direct Care Staff Daily Report forms from 9/13/21 through 10/4/21 revealed the facility failed to meet the minimum staffing requirement for CNAs on 9 out of the 22 days reviewed.

On 10/5/21 at 2:41 PM Staff 1 (Administrator) and Staff 2 (Scheduling Coordinator) acknowledged the facility was not staffed to state minimum CNA staffing ratios on 9 of the 22 days reviewed for CNA coverage.

OAR-411-085-0310: Residents' Rights: Generally

Refer to F585
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OAR-411-086-0110: Nursing Services: Resident Care

Refer to F684 and F697
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OAR-411-086-0140: Nursing Services: Problem Resolution & Preventive Care

Refer to F689
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OAR-411-086-0100: Nursing Services: Staffing

Refer to F725, F727 and F732
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